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PAIN 


PAIN 


ITS  ORIGIN,  CONDUCTION, 

PERCEPTION  AND  DIAGNOSTIC 

SIGNIFICANCE 


RICHARD  J.  BEHAN,  M.D 


6e 


:.«OHMEB   ASSOCIATE   PROFESSOR   OF  PHYSICAL   DIAGNOSIS,  WESTERN    PENNSYLVANIA  MEDICAL   COIiEC  y! 

(university  of   PITTSBURGH);    FORMER    ASSISTANT   SURGEON   AND   PATHOLOGIST,  ST.  FRANCIS* 

HOSPITAL,  PITTSBURGH;   MEMBER   A.  M.  A.,  DEUTSCHE  GESELL8CHAFT   FUR   CHIRURGIE, 

ETC.;    FORMER   VOLUNTEER   ASSISTANT   IN   CLINICS   OP   PROF.  H.    SCHLES- 

INGEB,  VIENNA,  AND   GEHEIMRAT   PROF.  BIER    BERLIN. 


WITH  ONE  HUNDRED  AND  NINETY-ONE 

ILLUSTRATIONS  IN  THE  TEXT  AND 

MANY  DIAGNOSTIC  CHARTS 


NEW  YORK    AND    LONDON 
D.    APPLETON    AND    COMPANY 

J921 


Copyright,  1914,  1920,  by 

D.  APPLETON  AND  COMPANY 


Printed  in  the  United  States  of  America 


IT    IS    WITH    THE    GREATEST    OF    PLEASURE 

THAT   I    DEDICATE    THIS   BOOK   TO    ONE 

WHO    HAS    EVER  BEEN  AS  A  FATHER 

TO   ME  AND  TO  WHOM    I   OWE    THE 

MOST    OF    WHAT    I    AM TO    MY    UNCLE 

MALACHY  O'DONNELL 


r 


!7 


/9t^- 


PEEFACE 

During  many  years  I  have  been  impressed  with  the  necessity 
of  a  thorough  understanding  of  pain  phenomena  in  the  making 
of  a  diagnosis.  Pain  is  universal,  and  is  present  in  practically 
every  disease,  and  in  most  diseases  it  is  the  one  symptom  which  first 
attracts  the  patient's  attention  and  causes  him  to  become  aware 
of  some  change  in  his  physical  well-being.  The  patient  then 
comes  to  the  physician,  who,  unless  he  is  well  versed  in  the  inter- 
pretation of  pain  phenomena,  may  be  at  a  loss  to  interpret  the 
symptoms  which  are  presented  to  him.  To  do  so  he  needs  to 
know  not  only  the  various  factors  to  which  a  certain  pain  may 
be  due,  but  also  the  reasons  why  it  should  be  produced  and  the 
different  diseases  giving  rise  to  pain  of  similar  character  and  loca- 
tion. To  understand  thoroughly  these  latter  factors  the  physician 
must  needs  be  versed  in  all  the  essentials  and  components  of  which 
a  pain  consists,  its  causes,  character,  varieties,  its  localizations 
and  the  changes  induced  by  its  presence. 

It  was  with  the  idea  of  supplying  easily  accessible  informa- 
tion along  these  lines  that  I  undertook  the  composition  of  this 
book.  To  those,  who,  like  myself,  have  felt  the  need  of  such  a 
book,  I  offer  it  with  the  hope  that  it  may  be  of  some  help  to  them. 
To  make  it  as  complete  as  possible  has  been  my  endeavor,  and  to 
do  so  I  have  thoroughly  searched  the  literature  and  culled  from  it 
all  that  I  thought  might  be  of  use.  I  believe  credit  has  been 
given  in  all  cases  to  the  authors  of  my  references,  but  if,  through 

vii 


viii  PREFACE 

an  unintentional  oversight,  this  has  been  neglected,  I  beg  that  my 
attention  may  be  called  to  it  so  that  it  can  be  remedied. 

It  is  with  the  gTeatest  pleasure  that  I  express  my  thanks  to 
Dr.  T.  L.  Disque,  Dr.  Wm.  H.  Glynn,  Dr.  E.  C.  Stuart,  who  so 
kindly  granted  me  the  use  of  an  abundant  material  from  his 
surgical  service;  to  Goldsmith  of  Vienna,  who  reviewed  the 
anatomical  section  of  my  work ;  to  Dr.  Frankel  of  the  same  city, 
who  reviewed  my  gynecology  section;  to  Dr.  Smith  Ely  Jelliffe, 
who  has  reviewed  the  entire  work ;  to  Mr.  Sander  of  Vienna ;  and 
Dr.  Frenzel  and  Dr.  Powers  of  Berlin ;  to  Miss  Esther  Hrubesky 
of  Berlin,  who  has  aided  me  in  revising  my  proofs  and  illustrations. 

R.    J.    Behan. 


CONTENTS 

CHAPTER    I 
GENERAL    CONSIDERATION    OF    SENSATION 

'  PAGB 

Sensation  in  Lower  Animals      .......  1 

Reaction  of  Animals  to  Pain 3 

General  Consideration  of  Sensation          .....  4 

Properties  of  Sensation    ........  7 

Centers  for  Sensory  Perception  and  the  Sense  Organs      .         .  8 

Sense  Perceptive  Organs    ........  11 

Stimuli       ...........  12 

Interpretation  of  Sensation      .......  13 


CHAPTER   II 
THE   NATURE    OF   PAIN 


Definition  ....... 

Metaphysical  Consideration  of  Pain 

Memory  Centers  for  Pain         .... 

Causative  Factors  in  the  Production  of  Pain    . 
Apparatus  for  Receiving  and  Conducting  Pain 
Pain  and  Mental  States     ..... 

Relation  op  Pain  to  Other  Sensations 
Conveying  Channels  for  Sensations 


18 
20 
24 
25 
28 
30 
31 
35 


CHAPTER   III 
DISTRIBUTION    OF    THE    SENSATION    OF   PAIN 
Distribution  of  the  Sensation  of  Pain      .         ... 


40 


CHAPTER   IV 

PERCEPTION    OF   PAIN    SENSATION 

Analgesia 61 

Anesthesia 63 

Hyperalgesia 67 

iz 


CONTENTS 


Tenderness 
Paresthesia 


PAGE 

70 
73 


CHAPTER   V 
CLASSIFICATION    OF   PAIN 


Subjective  Pains 

Emotional  pains 

Hysteria 

Hypnosis 

Habit  pains  . 

Monomania  pains 

Occupation  neuroses 
Objective  Pains 

Central  objective  pain 

Peripheral  objective  pain 


74 

76 
76 
80 
80 
80 
80 
82 
82 
83 


CHAPTER   VI 
CLASSIFICATION    OF    PAIN    (Continued) 


Peripheral  Objective  Pains 
Propagation  of  pains 
Character  of  the  pain 
Persistency  of  pain 
Time  of  the  pain    . 
Sensitiveness  to  pain 
Individual  susceptibility 


CHAPTER  VII 
THE  INTENSITY  OF  PAIN 

Factors  upon  Which  Intensity  Depends 

The  stimulus 

Sensitiveness  of  the  patient 

Centric  increased  irritability    . 

Irritability  of  the  nerves 

Extent  and  number  of  nerve  fibers  involved 
Factors  Modifying  Pain  Production 

Psychical  factors   . 

Physical  factors 
Estimation  of  the  Intensity  of  Pain 

Blood-pressure   elevation 

Motor  reflexes 

Complaints  of  patient  compared  with  his  susceptibility 

Vasomotor  signs     .,,,,,, 


89 
89 
108 
109 
110 
111 
112 


114 
114 
115 
115 
115 
115 
115 
115 
116 
120 
120 
122 
123 
124 


CONTENTS 

xi 

PAGE 

Dilatation  of  the  pupil 

.     125 

Amount  of  morphine  necessary  to  overcome  pain 

.     125 

Appearance  of  patient  . 

. 

.     125 

Patient's  description 

. 

.     128 

Mechanical  factoi-s 

. 

.     129 

Conditions  Associated  with 

Severe  Pain 

.     132 

Respiratoiy  system 

. 

.     134 

Circulation     . 

. 

.     134 

Loss  of  equilibrium 

. 

.     134 

Trophic  changes    . 

. 

.     134 

Preprotective  functions  . 

,         . 

.     135 

Elevation  of  temperature 

. 

.     135 

Method  of  Recording  Pain 

,         , 

.     135 

CHAPTER   VIII 
PAIN    IN*  DISEASES    OF    THE    NERVES,    BRAIN,    AND    CORD 


Affections  of  the  Nerve  Terminals  and  Nerve  Trunks 

Etiology         ....... 

SjTiiptoms      ....... 

Duration  of  neuralgia     ..... 

Diagnosis  of  neuralgia   ..... 

Types  of  neuralgia  according  to  localization 
Central  Nervous  System    ..... 

Anatomy        ....... 

Origin  of  headache         ..... 

Headache  in  disease  of  the  brain  and  meninges 

Leptomeningitis  purulenta        .... 

Brain  tumor  ....... 

Diagnosis  of  headache  in  diseases  of  the  brain  and  meninges 

Differential  diagnosis       ....... 

CHAPTER   IX 
DISEASES    OF    THE    SPINAL    CORD 


140 
142 
143 
146 
146 
147 
172 
173 
175 
178 
180 
182 
190 
195 


Cord  Conditions  "Which  Cause  Pain  . 

Meningeal  apoplexy        .... 

Hematomyelia         ..... 

Caries  of  the  vertebral  canal 
Tumors  of  the  spinal  cord  and  vertebrae 
Acute   spinal   meningitis 
Pachymeningitis  spinalis  hypertrophica     . 
Myelitis  ...... 

Poliomyelitis  of  children 

Syphilis  of  the  meninges  and  of  the  cord 

Multiple  sclerosis  ,         ,         ,         .         , 


208 
209 
210 
210 
211 
212 
212 
212 
212 
213 
213 


3rii  CONTENTS 

PAGE 

Syringomyelia        .........  214 

Tabes  doi-salis        .........  214 

Neurasthenia           .........  215 

Hysteria 216 

Traumatic  neuroses         ........  216 

General  summary  .........  216 

CHAPTER   X 
PAIN   IN    THE    TISSUES 

Muscular  Tissues 218 

Voluntary  Muscles 219 

Myositis 219 

Acute  polymyositis         ........  220 

Myositis  hemon-hagica   ........  221 

Mj'Ositis  fibrosa      .........  221 

Myositis  ossificans          ........  221 

Myalgia .         .221 

Involuntary  Muscles          .        • 222 

Colics 222 

Fatty  Tissues 224 

Adiposis  dolorosa  .........  224 

CHAPTER   XI 

BONE   PAINS— THE    OSTALGIAS 

General  Considerations 226 

Types  op  Pain 227 

Continuous  pains  .         .         .         .    *     .         .         .         .         .  227 

Intermittent  pain  .........  227 

Diurnal  variation  of  the  pains       ......  228 

Character  of  Bone  Pain    ........  228 

Localized  Bone  Pain  .........  228 

Periosteal  lesions  .........  229 

Traumatism 229 

Fracture 229 

Contusions     ..........  230 

New  growths          .........  230 

Septic  involvement          ........  231 

Generalized  Bone  Pain       ........  232 

Osteomalacia           .........  232 

Diseases  of  the  hemopoietic  system         .         .         .         .         .  233 

Sarcoma  and  carcinoma          .......  233 

Myeloma,  lymphadenoma  ossium,  and  chloroma       .         .         .  233 


CONTENTS  xiii 

PAGE 

Osteitis  deformans          ........  233 

Leontiasis  ossea     .........  233 

Spurs 233 

Differential  Diagnosis  op  Bone  Pain       .....  233 

Joint  Pains — Arthralgia    ........  234 

Classification           .........  234 

Radiation  of  joint  pains         .......  236 

Intensity  of  the  pain     ........  236 

Symptoms      ..........  236 

Diagnosis  of  inflammatory  joint  pains     .....  239 

Hip  joint 240 

Tension  pain  of  intra-artieular  hip-joint  abscess         .          .          .  244 


CHAPTER   XII 
THE   CIRCULATORY   SYSTEM 
Pain  Caused  by  Changes  in  the  Blood 

Pains  from  increase  in  blood  supply 

Pains  from  diminution  in   blood   supply 
Arterial  Diseases  Causing  Pain 

Inflammation  ...... 

Increase  of  blood  pressure 

Intermittent  claudication         .... 

Erythromelalgia     ...... 

Embolism  and  thrombosis  of  the  mesenteric  arteries 

Aneurysm      ....... 

Diseases  of  the  Veins  Causing  Pain 

Inflammation  of  the  veins       .... 

Thrombosis    ....... 

Varicose  veins    ...... 


247 
247 
248 
249 
250 
251 
251 
252 
253 
254 
255 
255 
256 
256 


CHAPTER   XIII 

THE    GLANDULAR    TISSUES 

The  Glands 257 

The  Mammary  Gland 257 

The  Adrenals     ..........  259 

The  Mesenteric  Glands 261 

The  Thymus  and  Thyroid 261 


CHAPTER   XIV 

REGIONAL   PAIN 

The  Head 262 

Sense  of  pressure  in  head       .......  264 

Head  pain     ..........  265 

Diagnosis  of  headache    .,.,,..,  281 


xiv  CONTENTS 

PACE 

Pain  in  the  Back 296 

Lungs 300 

Heart  and  aorta     .........  301 

Stomach 301 

Intestines 302 

Liver  and  gall-bladder    ........  302 

Kidney 302 

Pancreas,  spleen,  etc.      ........  303 

Anemia  and  chlorosis     ........  304 

Pain  in  the  Limbs 304 

Pain  in  the  Abdomen 307 

Chest  Pain 310 

Clavicular  Pains 310 

Neck  Pains 312 

Summary    ...........  312 


CHAPTER   XV 
THE   SIGNIFICANCE   OF   PAIN   IN   DISEASE    OF   THE    EYE 

Etiology 317 

Localization  of  Pains         ........  318 

The  eyelids 318 

Surroundings  of  the  eye         .......  322 

Conjunctiva  and  cornea  .......  322 

The  iris  and  ciliary  body         .......  325 

Sclerotic  coat         .........  327 

Choroid,  retina  and  optic  nen'e     ......  328 

Glaucoma      ..........  329 

Panophthalmitis     .........  330 

Asthenopic  disordei-s       ........  330 


CHAPTER   XVI 

PAIN    IN    DISEASE    OF    THE    EAR 

External  Ear 332 

External  Auditoey  Canal  ........  333 

Tympanum 335 

Middle-ear  Disease     .         ........  335 

Middle-ear  Catarrh    .........  339 

Otosclerosis 339 

Labyrinth           ..........  339 

Keferred  Pain 340 


CONTENTS  XV 


CHAPTER   XVII 
PAIN   IN   DISEASES    OF    THE   NOSE 

PAGE 

The  Sensory  Nerves  of  the  Nose        ......  341 

Diseases  "Which  Produce  Pain  and  Their  Manner  of  Production  342 

Nasal  Stenosis  ..........  342 

Empyema    ...........  343 

Headache  from  Disease  of  the  Sphenopalatine  Ganglion         .  345 

Tumors 347 

Diagnosis .  348 


CHAPTER   XVIII 
PAIN   IN   DISEASES    OF    THE   THROAT 

Pain  in  Diseases  op  the  Pharynx      .....         i.  351 

Pain  in  acute  diseases     ........  351 

Pain  in  chronic  diseases         .......  354 

Pain  in  the  Larynx  .........  356 

Pain  in  acute  affections         .......  357 

Chronic  processes  .........  358 


CHAPTER   XIX 

ABDOMINAL   PAIN 

Classification 360 

Subjective  Pain 360 

Objective  Abdominal  Pain         .......  360 

Inflammations  of  the  Peritoneum     ......  364 

Tumors  of  the  Peritoneum        .......  367 

Nature  of  Pain  from  Adhesions 367 

Nature  of  Pain  in  Hernia 371 


CHAPTER   XX 

PAIN   IN   ABDOMINAL   VISCERAL   DISEASE 

History 377 

Location  of  Pain      .........     383 

Transference  of  Pain 38f 


ZVl 


CONTENTS 


CHAPTER   XXI 
DIAGNOSIS    OF   ABDOMINAL   PAINS 


Nature  of  Various  Abdominal  Pains  • 

Examination  for  Pain        .... 
Localization  of  pain       .... 
Localization  of  organ  producing  pain 
Lesions  causing  epigastric  pain 
Pain  due  to  functional  processes     . 
Pain  due  to  intestinal  diseases 
Abdominal  tenderness     .... 

Posture  in  Abdominal  Diagnosis 

Forms  of  Abdominal  Pain 

Functional  pains  ..... 
Care  in  diagnosis  ..... 

Conditions  Associated  with  Abdominal  Pain 
Spasm  and  rigidity  of  muscles 
Visceromuscular  reflex   .... 

Toxemia         ...... 

Indicanuria   ...... 

Polyuria         ...... 

Relationship  of  hysterical  to  abdominal  pain 
Abdominal  incisions        .  .         '.  . 

Post-operative  abdominal  pain 
Pain  refeiTed  to  extra-abdominal  regions 
Absence  of  pain    ..... 


PAGE 

390 
394 
394 
395 
396 
400 
401 
403 
406 
408 
409 
410 
413 
413 
413 
414 
414 
414 
414 
415 
415 
416 
416 


CHAPTER   XXII 
PAINS    OF    THE   ALIMENTARY   TRACT 


Lips    .... 

Cheeks       .         .        . 

Teeth 

Tongue 

Salivary   Glands 

Pharynx  and  Tonsils 

Esophagus 


418 
418 
419 
421 
422 
423 
424 


CHAPTER   XXIII 
THE   STOMACH 

Areas  of  Referred  Pain  Caused  by  Stomach  Disorders 
Pain  in  Gastric  Areas 

Character  of  gastric  pain         ..... 

Time  and  manner  of  its  appearance 


427 
429 
429 
430 


CONTENTS 

Relationship  to  ingestion  of  food     . 

Duration  of  pain  .  . 

Previous  attacks    ..... 

Associated  symptoms      .... 

Pain  reflected  or  referred  to  gastric  areas 
Lesions  of  Stomach  Causing  Pain     . 

Displacement  of  the  stomach  (gastroptosis) 

Gastralgia  or  gastromyalgia    . 

Hyperchlorhydria  .... 

Pyloric  or  cardiospasm 

Acute  dilatation  of  the  stomach     . 

Acute  gastritis       ..... 

Chronic  gastritis    ..... 

Gastric  erosions     ..... 

Gastric   ulcer         ..... 

New  growths  of  the  stomach 

Perigastric  adhesions  .... 
Referred  Pains  Confused  with  Those  of  Gastric  Origin 


XVH 
PAGt 

430 
430 
431 
431 
431 
431 
431 
431 
434 
436 
439 
440 
442 
442 
442 
455 
459 
461 


CHAPTER   XXiy 


INTESTINAL   PAIN 


General  Considerations     . 

.     463 

Etiology  of  pain   .... 

.     463 

Location  of  pain 

.     469 

Type  of  pain         .... 

.     470 

Manner  of  onset    .... 

.     471 

Relation  of  the  position  of  the  patient  to  the  pain 

.     472 

Relation  of  the  ingestion  of  food  to  the  pain 

.     472 

Duration  of  pain  ...... 

.     473 

Result  and  history  of  the  pain 

.     473 

Tenderness    ..... 

.     474 

Symptoms  associated  with  the  pain 

.     474 

Lesions  of  the  Intestines  Causing  Pain 

.     476 

Enteralgia  ' 

.     476 

Pain   due   to   functional   disturbances 

.     477 

Type  of  pain  in  colic     . 

.     483 

Inflammation  of  the  bowel 

.     484 

Ulcers  of  the  intestine     . 

.     487 

Distention  of  the  bowel 

.     491 

Adhesions 

.     491 

Obstruction  of  the  intestine     . 

.     492 

The  rectum  ..... 

.     505 

The  anus       

.     509 

xviii  CONTENTS 

CHAPTER   XXV 
THE   APPENDIX 

PAGE 

Varieties  of  Appendiceal  Pain 516 

Tenderness  in  Appendicitis        .......  529 

Symptoms  Associated  with  Pain  Production  in  Appendicitis      .  535 

Differential  Diagnosis       ........  537 

CHAPTER   XXVI 
THE   LIVER,    GALL   BLADDER   AND    DUCTS 

General  Considerations     ........  540 

Nerve  supply         .........  540 

Pain  op  the  Liver       .         .         .         .         .         .         .         .         .  545 

Character  of  the  pain     ........  545 

Relation  to  the  ingestion  of  food  and  drink     ....  545 

Relation  to  the  movement  of  the  body     .....  547 

Position  of  the  body     ........  547 

Relationship  to  other  diseases  and  processes     ....  548 

Time  of  appearance   of  pain         ......  549 

Neuralgia       ..........  550 

Pains  due  to  the  disturbance  of  the  liver  substance  proper         .  550 

Gall  Bladder 562 

General  etiology     .........  562 

Diagnosis       ..........  563 

Diseases  causing  pain     ........  568 

Gall-duct  Pain  . 572 

Etiology 572 

Location  of  pain    .........  573 

Character  of  pain  .........  573 

Associated  symptoms      ........  576 

Differential  diagnosis      ........  577 

CHAPTER   XXVII 

THE   PANCREAS 

General  Considerations 580 

Nerve  supply         .........  581 

Structure  of  the  pancreas         .......  582 

Peritoneal  covering         ........  583 

Relationship  to  other  parts     .......  584 

Character  of  pain  ......••.  585 

Location  of  pain    .........  585 


CONTENTS 

xlx 

PAGE 

Tenderness 586 

Position  of  the  patient   .... 

• 

.     587 

Diseases  of  the  Pancreas  Causing  Pain 

.     587 

Pancreatitis  ...... 

, 

.     587 

Pancreatic  calculi           .... 

. 

.     580 

. 

.     591 

Cancer  of   the   pancreas 

• 

.     591 

CHAPTER   XXVIII 

THE    SPLEEN 

General  Considerations 593 

Anatomy 

.     593 

Nerve  supply         ..... 

.     593 

Position  of  patient         ..... 

.     596 

Tenderness 

.     596 

Factors  influencing  pain 

.     596 

Disorders  of  the   Spleen   Producing  Pain 

.     598 

Displaced  or  movable  spleen 

.     598 

Congestion     ....... 

.     599 

Perisplenitis            ...... 

.     600 

Abscess  of  the  spleen 

.     601 

Infarct           

.     601 

Rupture  of  the  spleen 

.     602 

Tumors  of  the  spleen     ..... 

.     602 

Cysts  of  the  spleen        ..... 

.     602 

CHAPTER   XXIX 
THE  KIDNEY 

General  Considerations 

Nerve  supply 

Etiology  of  kidney  pain 

Character  of  renal  pain 

Localization  of  kidney  pain 

Tenderness     . 

Factors  influencing  production  of  pain 

Absence   of  pain   in  kidney   lesions 

Symptoms  associated  with  pain  phenomena 

Pain  in  diagnosis  of  kidney  lesions 
Differential  Diagnosis  of  Kidney  Diseases  Causing 

Movable  kidney 

Renal  infarction    . 

Hematuric  nephralgia     . 

Inflammation  of  the  kidney 


Pain 


604 
601 
605 
607 
607 
615 
617 
618 
618 
619 
620 
620 
626 
629 
629 


XX  CONTENTS 

PACE 

Perinephritis 637 

Rupture  of  the  kidney  ........  641 

Tuberculosis  of  the  kidney     .......  642 

New  growths         .........  644 

Pyelitis 647 

Hydronephrosis      .........  653 

Renal  calculus        .........  655 

CHAPTER   XXX 
THE   URETER,    BLADDER   AND   URETHRA 

The  Ureter 670 

The  Bladder 672 

General  considerations   ........  672 

Bladder  affections   causing   pain     ......  683 

The  Urethra      ..........  695 

Urethral  caruncles           ........  695 

Calculus         ..........  696 

Rupture   of   the   urethra         .......  696 

Transfen-ed  pain  in  urethral  disease       .....  696 

Pain  on   urinating         ........  696 

CHAPTER   XXXI 
THE   MALE   ORGANS    OP   GENERATION 

The  Testicles 698 

Epididymis,  Vas  Deferens,  and  Seminal  Vesicles       .         .         .  699 

The  Prostate .  700 

Congestion  and  inflammation           ......  700 

Lesions           ..........  701 

Hypertrophy          .         .         .         .         .         .         .         .         .  701 

Tumors   of  the  prostate         .......  702 

Tuberculosis            .........  702 

Associated  symptoms     ........  702 

The  Penis ,      '   .  703 

Urethritis 703 

Inflammation   of   the   prepuce         ......  703 

Inflammation  of  Cowpei''s  glands     ......  703 

CHAPTER   XXXII 
PAIN   IN    THE   FEMALE    GENITALIA 

General  Considerations 705 

Anatomy        .......*••  705 

Nerve  supply         .........  705 


CONTENTS 

xxi 

PAGE 

Diagnosis   of  pelvic   and   hysterical   pain         ....     709 

Varieties  of  pain   ..... 

.     712 

Character  of  uterine  pains 

.     716 

Diagnosis  of  the  pelvic  diseases 

.     722 

Uterine  Pain     .... 

.     724 

Character  of  uterine  pains     . 

.     724 

Neuralgia       .... 

.     726 

Displacement  of  the  uterus     . 

.     726 

Functional  disorders  of  the  uterus 

.     728 

Inflammation  of  the  uterus 

.     740 

New  growths  of  the  uterus     . 

.     743 

Fallopian  Tubes 

.     744 

Tubal  conditions  causing  pain 

.     744 

Extrauterine  pregnancy 

.     746 

Ovary          

.     747 

Local  point  of  pain 

.     748 

Causes  of  pain      .... 

.     748 

Neuralgia   of   the   ovary 

.     749 

Displacement  of  the  ovary     . 

.     749 

Hernia  of  the  ovary     . 

.     749 

Hyperemia  of  the  ovary 

.     749 

Abscess  of  the  ovary     . 

.     751 

Tuberculosis            .... 

.     752 

Enlarged  uterus     .... 

.     752 

Relationship  of  ovaries  and  parotids 

3 

.     752 

Cysts  of  the  ovary 

.     753 

The  Vagina 

.     755 

Nerve  supply 

.     755 

Affections  causing  pain  . 

.     755 

Sexual  connection  . 

.     756 

CHAPTER   XXXIII 
PAIN   IN   THE   CHEST 


The  Thoracic  Walls 

The  skin 

Muscles,  fascia  and  nerves 

Nerve  and  muscle  pain  . 

Bone  pain     . 

Pleural    pain 
Referred  and  Reflected  Pains  of  the  Thoracic  Walls 

Localization  of  pain  on  the  chest  wall 
Pains   w^ithin  the  Thorax 

The  pleura  ..... 


760 
760 
762 
762 
764 
764 
76^ 
767 
769 
769 


xxii  CONTENTS 

CHAPTER   XXXIV 
HEART   DISEASE 

PAGE 

General  Considerations 773 

Nerve  supply  of  the  heart 774 

Diagnosis  by  means  of  location  of  referred  pain     .         .         .  774 

Intracardiac  lesions  as  causes  of  pain 782 

Angina  Pectoris 783 

Etiology         ..........  783 

Character  of  the  pain  in  angina  pectoris         ....  784 

Location  of  the  pain     ........  785 

Local  tenderness     .........  787 

Associated  symptoms      ........  787 

Disease  of  the  Pericardium       .......  788 

CHAPTER   XXXV 
THE   RESPIRATORY   ORGANS 

The  Lungs 790 

General  considerations   ........  790 

Diseases  of  Thoracic  Organs  Causing  Pain        ....  795 

Acute  bronchitis    .........  795 

Pneumonia    ..........  797 

Tuberculosis           .........  800 

The  Mediastinum 802 

BIBLIOGRAPHY 805 

INDEX 869 


LIST   OF   ILLUSTRATIONS 

FIG.  PAGE 

1. — Right   cerebral  hemisphere  seen   from   the  outside         .  .         9 

2. — Inner  surface  of  right  cerebral  hemisphere     ....         9 

3. — Schematic  illustration  showing  how  the  various  sensations  are 
transmitted  from  the  periphery  to  the  brain  cortex  and 
from  thence  to  the  two  brain  centers         ....       23 

4. — Diagi-am  showing  how  changes   in   the   cell   metabolism  may 
produce  changes  in  the  irritability  of  the  cell  and  a  de- 
parture in  its  reaction  to  external  stimuli,  either  making 
it  more  or  less  sensitive  to  peripheral  irritation     .  .       27 

5. — Areas  of  epicritic  and  protopathic  sensibility         ...       38 
6.^-Effect  of  injury  to  the  pain-conduction  paths  in  the  cord         .       39 
7. — Unilateral  complete  lesion  on  one  side  of  the  cord  producing  a 
narrow  band  of  anesthesia  on  the  same  side  at  the  level  of 
the  lesion  and  a  broader  zone  of  anesthesia  on  the  opposite 
side  slightly  below  the  level  of  the  lesion         ...       39 
8. — Cross  section   of  the   spinal  cord         .....       40 

9. — Diagram  showing  intraspinal  course  of  sensory  fibers     .  .       43 

10. — Course  of  the  different  sensory  (peripheral)  fibers,  according 

to  Head       .         .         .         .         .         .         .         .         .44 

11. — Cutaneous  sensoiy  nerve  supply  to  the  lower  limbs.     (After 

Toldt.) 49 

12. — Cutaneous  distribution  of  peripheral  nerves.     (After  Fowler.)       50 
13  and  14. — Cutaneous  nerve  supply,  showing  the  distribution  areas 

of  the  different  plexuses.     (Toldt.)         ....       51 

15. — Distribution  areas  of  the  nerves  (from  lumbar  plexus)  distrib- 
uted to  the  anterior  surface  of  the  thigh  and  abdomen     .       52 
16. — Distribution  of  the  nerves  derived  from  the  sacral  plexus         .       53 
17. — Dorsal  nerves      .........       54 

18. — Cord  zones  according  to  Kocher     ......       55 

19. — Cutaneous  areas  related  to  spinal  cord  segments  and  cutaneous 

distribution  of  nerves     .......       56 

20. — Areas  of  anesthesia  and  paralysis  corresponding  to  affected 

vertebra3        .........       57 

21. — Distribution  of  the  lumbar  segments   according  to  Thorbum       57 
22. — Distribution   of  lumbar  and   sacral   segments   as  outlined  by 

Starr 57 

zziii 


xxiv  LIST    OF    ILLUSTRATIONS 

FIG.  PAGE 

23. — Relationship  of  the  segments   of  the  spinal   cord  and  their 

nerve  roots  to  the  bodies  .and  spines  of  the  vertebrje         .  58 
24. — Cord  zones  and   areas   of  maximum  tenderness  according  to 

Head 59 

25. — Cord  zones  and  areas  of  maximum  tenderness  according  to 

Head 59 

26. — Cord  zones  and  areas  of  maximum  tenderness  according  to 

Head 59 

27. — Areas  of  anesthesia  on  leg  due  to  depressed  fracture  of  skull  64 

28. — Method  of  eliciting  hyperalgesia  .         .         .         .         .         .  67 

29. — Areas  of  analgesia  in  "hysteria     ......  78 

30. — Method  of  pain  production  in  inflammation         ...  85 

31, — Varieties  of  pain :     Origin   and   transmission         ...  89 
32. — Scheme  showing  how  the  different  varieties  of  pain  may  arise 

and  how  the  different  musculo-sensory  reflexes  may  occur  90 

33. — Varieties  of  pain:     Origin   and  transmission         ...  91 

34-36. — Case  illustrating  upward  reference  of  pain     ...  99 
37. — Hand  pressing  on  the  abdomen,  very  characteristic  of  colic, 

i.e.,  of  the  uterus  or  intestine         .....  126 
38. — Position  assumed  in  uterine  colic,  intestinal  colic,  and  distended 

urinaiy  bladder     ........  127 

39. — Lacing  shoe  position     ........  128 

40. — Pain  on  hyperextension  of  the  body     .....  129 

41. — Pain  on  going  upstairs         .......  129 

42. — Marking  code  of  Dr.  Harris 136 

43. — Figures  showing  the  application  of  the  marking  code  of  Dr. 

Harris           .........  137 

44. — Areas  of  neuralgic  pain       .......  148 

45. — Brachial  plexus  .........  151 

46. — Areas   of   distribution   of  nerves   derived   from   the  brachial 

plexus           .........  152 

47. — Areas   of  distribution   of  nerves   derived   from   the   brachial 

plexus           .........  152 

48. — Distribution  areas  of  the  cutaneous  nerves  of  the  upper  limbs  154 
49. — Areas  of  distribution  of  the  different  cords  of  the  brachial 

plexus           .........  155 

50. — Distribution  of  sensory  disturbances  in  a  lesion  of  the  fifth 

cervical  nei've        ........  156 

51. — Area  of  distribution  of  pain  in  lesions  of  the  sixth  and  seventh 

cervical  nerve       ........  156 

52. — Distribution  of  sensory  disturbances  in  lesions  of  the  cervical 

plexus           .........  157 

53. — Area  of  anesthesia  in  a  lesion  of  the  first  dorsal  nei-ve     .          .  157 

54. — Method  of  eliciting  pain  in  brachial  neuralgia         .         .         .  158 


LIST    OF    ILLUSTRATIONS 

FIG. 

55. — Method  of  eliciting  the  points  of  tenderness  in  intercostal 
neuralgia       ......... 

56. — Cutaneous  distribution  areas  of  small  and  greater  sciatic 

57. — Method  of  eliciting  pain  in  sciatica 

58. — Distribution  of  the  plantar  nerves 

59. — Pain  in  skin  over  back  and  shoulder  due  to  disease  of  shoulder 
joint     ...... 

60. — Obturator  and  accessoiy  obturator 

61. — Pain  areas  in  the  head 

62. — Pain  areas  in  the  head 

63. — Figure  illustrating  the  places  where  induration  takes  pi 

64. — Locations  of  the  principal  headaches 

65. — Locations  of  the  principal  headaches 

66. — Occipital  headache       .... 

67. — Fronto-temporal  headache     . 

68. — Temporal  headache       .... 

69.     Frontal  view  of  Head's  zones     . 

70. — Lateral  view  of  Head's  zones     . 

71. — Lateral   view   of   Head's   zones 

72. — Posterior  view  of  Head's  zones     . 

73. — Figure  showing  the  modifications  of  pain  in  the  lumbar 
by  change  of  position   . 

74. — Pain  areas  in  trunk  and  lower  extremities 

75. — Pain  areas  in  breast  and  abdomen 

76. — Pain  areas  in  neck,  chest,  clavicular  region  and  abdomen 

77. — Pain  areas  in  the  back         .... 

78. — Pain  areas  in  spinal  column 

79. — ^Pain  areas  in  back     ..... 

80. — Posture  assumed  in  earache 

81. — Scheme  of  innervation  of  abdominal  \ascera 

82. — Figui'e  shelving  the  anterior  distribution  of  the  ninth,  tenth, 
eleventh  and  twelfth  dorsal  nei-ves 

83. — Anterior  view  of  abdominal  zones  with  corresponding 

84. — Posterior  view  of  abdominal  zones 

85. — Areas  of  local  tenderness,  when  the  inflammation  of  the  appen- 
dix, gall  bladder,  and  Fallopian  tube  and  ovary  has  spread 
to  the  peritoneum  and  has  produced  a  localized  peritonitis 

86. — Posture  of  abdominal  protection  present  in  peritonitis     . 

87. — Position  in  abdominal  colic,  assumed  on  lying 

88. — Position  in  abdominal  colic,  assumed  on  sitting     . 

89. — Areas  of  referred  pain  as  given  by  Head         .... 

90. — Nervous  supply  of  the  stomach    ...... 

91. — Location  of  the  pain  symptoms  in  a  ease  of  hyperchlorhydria 

92. — Pain  radiation     ......... 

93. — Location  of  pain  in  acute  gastritis         ..... 


XXV 


164 
167 
168 
169 

235 
240 
263 
264 
266 
278 
279 
280 
280 
281 
291 
292 
293 
294 

298 
308 
309 
311 
313 
314 
315 
335 
379 

385 
395 
396 


404 
406 
407 
407 
427 
428 
435 
436 
441 


xxvi  LIST  OF  ILLUSTRATIONS 

FIG.  PAGE 

94. — Location  of   pain  in  gastiic   ulcer        .....  443 

95. — Sites  of  tenderness  in  gastric  ulcer,  ulcer  of  pylorus  and  ulcer 

of  duodenum         .         .         .         .         .         .         .         .  446 

96. — Sites  of  tenderness  in  gastric  ulcer,  posterior  view         .         .  446 
97. — Hyperalgesic  zones  in  cancer  at  cardiac  end  of  stomach         .  456 
98, — Point  of  tenderness  and  the  area  of  pain  in  a  case  of  peri- 
gastric adhesions  ........  460 

99. — Anterior  \'iew  of  areas  of  referred  pain  in  intestinal  diseases  466 

100. — Posterior  view  of  areas  of  referred  pain  in  intestinal  diseases  466 
101. — Points  to  which  pain  is  referred  in  lesions  of  different  parts  of 

intestinal  tract       ........  467 

102. — Pain  areas  in  colonic  colic    .......  481 

103. — Pain  areas  in  intussusception  .......  498 

104  and  105. — Areas  of  pain  in  diseases  of  colon     ....  500 

106. — Irritation  at  external  sphincter  referred  to  skin  over  coccyx     .  510 
107. — Cutaneous  and  muscular  distribution  of  eleventh  and  twelfth 

thoracic  nerves     ........  515 

108. — Areas  supplied  by  the  posterior  branches  of  the  eleventh  and 

twelfth  thoracic  nerv^es           ......  520 

109. — Areas  of  pain  referred  from  the  appendix     ....  521 

110  and  111. — Areas  of  cutaneous  hyperalgesia  in  appendicitis  cor- 
responding to  the  eleventh  dorsal  area  of  Head       .         .  522 
112. — Reflected  pain  in  appendicitis.     Triangle  of  cutaneous  tender- 
ness     ..........  523 

113. — Reflected  pain  in  appendicitis.     Small  area  of  cutaneous  ten- 
derness occasionally  present  ......  523 

114. — Reflected  pain  in  appendicitis.     Rounded  patch  of  cutaneous 

tenderness  in  lumbar  region   ......  523 

115. — Location  and  radiation  of  sympathetic  reflected  pain  in  appen- 
dicitis              524 

116. — Location  and  radiation  of  sympathetic  reflected  pain     .          .  524 
117. — Areas  of  hyperalgesia  in  the  eleventh  dorsal  visceral  segment 

due  to  appendicitis  of  the  catarrhal  type         .         .         .  525 
118. — Areas  of  increased  sensitiveness  to  pain  and  to  touch  in  appen- 
dicitis           .........  526 

119-121. — Pain  in  the  left  side  in  appendicitis      ....  528 

122. — Areas  of  referred  pain  in  liver  diseases :  Anterior  view         .  541 
123. — Areas  of  referred  pain  in  liver  diseases :  Posterior  view         .  541 
124. — Areas  of  refeiTed  pain  in  liver  diseases:  Lateral  view  .         .  542 
125. — Relationship  of  ner\'e  supply  of  liver  to  cerebrospinal  and  sym- 
pathetic systems    .          .          .          ...          .          .          .  543 

126. — Area  of  greatest  tenderness  in  diseases  of  the  gall  bladder 

and    appendix        ........  564 

127. — Method  of  eliciting  gall-bladder  tenderaess     ....  565 

128. — Radiation  of  gall-bladder  pain  as  given  by  Schmidt     .          .  566 


LIST    OF   ILLUSTRATIONS  xxvii 

FIG.  PAGE 

129. — Nerve  supply  to  pancreas     ....          ,         .          .  581 

130. — Distribution  areas  for  pain  due  to  pancreatic  lesions     .         -.  582 

131. — Relation  of  pancreas' to  posterior  abdominal  wall         .          .  583 

132. — Pain  areas  in  disease  of  pancreas         .....  590 

133. — Points  of  pain  and  tenderness  in  diseases  of  the  spleen         .  595 

134. — Points  of  pain  and  tenderness  in  diseases  of  the  spleen         .  595 

135. — Method  of  palpating  for  splenic   tenderness         .          .          .  596 

136. — Location  of  the  kidney         .......  597 

137. — Areas  of  referred  and  reflected  pains  in  diseases  of  the  urinary 

apparatus     .........  609, 

138. — Nerves  involved  in  refeiTed  pain  from  kidneys         .          .          .  611 
139. — Distribution    of    cord    zones    (according    to    Head)     and    of 

ner\'es            .........  613 

140. — Areas  of  reflected  hyperalgesia,  in  tenth,  eleventh  and  twelfth 

dorsal,  and  first  lumbar  visceral  segments    (according  to 

Head) 614 

141. — Method  of  palpation  in  eliciting  tenderness  in  the  kidneys     ,  615 
142. — Position    assumed   in    kidney   disorders,    ureteral    and   kidney 

colic,  lumbago,  uterine  and  tubal  adhesions  and  drag  on 

back,  enteroptosis,  especially  after  removal  of  corset       .  617 

143. — Area  of  hyperalgesia  in  congestion  of  kidney         .          .          .  631 
144. — Areas  of  hyperalgesia  in  congestion  of  kidney  associated  with 

liver  congestion  :  Anterior  A-iew       .....  634 
145. — Areas  of  hyperalgesia  in  congestion  of  kidneys  associated  with 

liver  congestion :  Posterior  view     .....  634 

146. — Area  of  hj'peralgesia  in  kidney  and  liver  congestion         .          .  635 

147. — Area  of  hyperalgesia  in  nephritis         .....  636 

148  and  149. — Areas  of  tenderness  present  in  renal  tuberculosis         .  643 

150. — Areas  of  distribution  of  anterior  spinal  nerves     .          .          .  660 

151. — Areas  of  distribution  of  posterior  spinal  nerves     .          .          .  660 
152. — Head   zones   of   hyperalgesia   usually   associated   with   kidney 

lesions :  Anterior  \dew  .......  661 

153. — Head   zones   of  hyperalgesia  usually   associated   with   kidney 

lesions :  Posterior  ^^ew  .......  661 

154. — Area  of  cutaneous  hyperalgesia  in  severe  renal  colic  in  which 

the  stone  was  in  the  ureter     ......  662 

155. — Pressure  made  upon  ureter  in  endeavor  to  obtain  local  ten- 
derness         .........  663 

156. — Toumier's  points  of  pressure  in  kidney  and  ureter  lesions     .  664 
157. — Relationship  existing  between  pain  and  other  sensations  arising 

in  the  urinary  bladder  .......  673 

158. — Pain  areas  associated  with  diseases  of  bladder       .          .          .  674 

159. — Relationship  of  rectal  tenesmus  to  vesical  tenesmus         .          .  675 
160. — Areas   of   refen-ed   pains   usually    associated   with   disease   of 

urinary  bladder     ........  676 


PAGB 


xxviii  LIST    OF    ILLUSTRATIONS 

FIG. 

161. — Referred  pain  in  disease  of  bladder       .....     677 

162. — Referred  pain  in  disease  of  bladder       .  .  .  .  .     677 

163. — Referred  pain  in  disease  of  bladder       .....     677 

164. — Referred  pain  in  disease  of  the  bladder  due  to  involvement  of 

the  pudic  nerve     ........     679 

165. — Areas  of  cutaneous  tenderness  in  disease  of  the  epididymis     .     699 
166. — Areas  of  distribution  of  the  tenth  and  eleventh  dorsal  segments, 
and   the  first,   second   and  third   sacral   segments   on  the 
right  side     .........     701 

167. — Nerve  supply  of  female  genitalia  ......     706 

168. — Area   of  distribution   of   cord   segments   involved   in   uterine, 

ovarian,  and  tubal  diseases     ......     714 

169. — Points  of  tenderness    as   elicited   by   Donald   and   Licklej'^   in 

ovarian,  tubal,  and  uterine  diseases         ....     720 

170. — Areas  of  hyperalgesia  in  a  woman  two  months  pregnant      .     736 
171. — Phenomena  accompanying  tubal  disorders     ....     738 

172. — Areas  of  referred  i^ain  in  a  case  of  labor       ....     740 

173. — Areas  of  cutaneous  distribution  of  the  thoracic  segments      .     761 
174. — ^Points  at  which  the  intercostal  nerves  become  superficial      .     763 
175. — Location  of  tenderness  in  various  diseases  of  the  chest  and 

abdomen       .........     765 

176. — Location  of  hyperalgesic  zones  and  the  areas  of  pain  in  cardiac 

and  aortic  lesions         .......     775 

177. — An  area  of  hyperalgesia  corresponding  to  portions  of  the  sec- 
ond,  third   and   fourth   dorsal   zones       ....     776 

178. — Areas  of  cutaneous  and  deeper  hyperalgesia  in  a  case  of  acute 
dilatation  of  the  heart,  accompanied  by  acute  distention  of 
the  liver       .........     777 

179. — Hyperalgesic  area  in  a  case  in  which  the  myocardium  is  prob- 
ably in  a  state  of  intoxication       .... 

180. — Areas  of  pain  in  a  case  of  mitral  and  aortic  regurgitation 
181. — Area  of  sensory  disturbances  in  a  case  of  angina  pectoris 
182. — Communication  between  spinal  accessory  and  vagus 
183. — Emergence  of   the   spinal   accessory   from   imder  the   sterno- 
mastoid         ........ 

184. — Conducting  paths  for  impulses  from  the  heart 
185. — Points  of  emergence  of  the  dorsal  nerves  (anterior) 
186. — Areas  of  hyperalgesia  in  a  case  of  diaphi-agraatic  pleurisy 
187  and  188. — Areas  of  referred  pain  in  pleurisy  . 
189  and  190. — Figures  showing,  on  the  left  side,  the  areas  of  distri- 
bution of  pain  in  a  case  of  diaphragmatic  pleurisy  with 
effusion;  on  the  right,  the  areas  before  the  effusion  ap- 
peared .........     796 

191. — Some  of  the  areas  of  pain  and  tenderness  in  cardiac  and  pul- 
monary disease    ........     801 


778 
779 
785 
786 

787 
788 
791 
793 
794 


PAIN 


CHAPTER  I 

GENEEAL  CONSIDEEATION  OF  SENSATION 

To  those  who  are  interested  in  the  study  of  disease,  it  is 
scarcely  necessary  to  emphasize  the  value  of  the  correct  apprecia- 
tion of  pain  as  a  symptom.  The  importance  of  its  interpretation 
must  be  obvious.  Almost  ninety  per  cent,  of  all  diseases  either 
begin  with,  or  have,  pain  as  a  prominent  symptom  at  some  time 
during  their  course.  Therefore,  a  correct  diagnosis  can  hardly  be 
made  without  an  intensive  study  of  the  various  forms  of  pain. 

Sensation  in  Lower  Animals. — We  may,  therefore,  take  up 
with  profit  a  consideration  of  sensation,  of  which  pain,  as  a  psycho- 
logical entity,  is  but  a  part.  In  fact,  to  gain  a  comprehensive 
idea  of  pain,  it  is  necessary  to  begin  our  studies  with  those  organ- 
isms in  which  sensation  emerges  from  that  simple  state  in  which 
all  stimuli  are  responded  to  by  reflex  protoplasmic  movements,  of 
which  the  organism  has  no  perception. 

This  movement  according  to  Loeb  would  be  the  result  of  che- 
motropism.  All  protoplasm  is  attracted  by  certain  substances  and 
repelled  by  certain  other  substances,  the  attraction  and  repul- 
sion depending  upon  the  construction  of  the  protoplasm  and  the 
stress  of  its  need  or  avoidance  of  the  constituents  of  which  the 
other  body  is  composed.  Such  a  state  we  find  in  the  ameba.  In 
a  higher  organism,  as  the  medusa,  an  aggi'Cgation  of  cells  possesses 
the  same  threshold  of  irritability  for  certain  substances  and  thus 
they  respond  to  irritation  by  coordinated  motion  and  this  seems 
to  be  due  to  the  presence  or  absence  of  certain  ions  in  the  stimu- 

1 


2  GENERAL    CONSIDERATION    OF    SENSATION 

lating  substance.  (Na  ions  start  or  incrcacc  rhythmical  contrac- 
tions; Ca  diminish  the  rate  or  inhibit  such  contractions.)  Or 
should  the  cells  all  not  come  into  contact  with  the  exciting  factor, 
the  one  coming  into  contact  can  transmit  its  stimulus  to  other 
adjacent  cells  and  in  them  produce  a  similar  reaction  to  its  own. 
This  propagation  by  contraction  is  better  exampled  in  the 
Ciona  intestinalis,  where  as  a  means  of  communication  a  set  of 
cells  are  specially  differentiated  so  that  they  can  better  and  more 
quickly  carry  stimuli  from  one  structure  to  another.  In  other 
words,  conduction  is  their  function.  These  cells  arrange  them- 
selves into  special  groups,  etc.,  and  form  what  is  termed  the  nerv- 
ous system.  But  in  the  lowest  forms  of  life  the  nervous  system 
is  not  a  necessity,  but  only  an  auxiliary  in  the  life  economy  of  the 
animal,  as  demonstrated  by  Loeb.  He  removed  the  central 
nervous  apparatus  of  the  Ciona  intestinalis  and  found  that  it 
still  responded  to  a  mechanical  stimulus  of  one  group  of  muscles 
by  contraction  of  other  groups,  but  that  this  response  was  much 
slower  than  when  the  central  nervous  system  was  intact.  From 
this  he  conduced  that  while  the  central  nervous  system  was  not 
absolutely  necessary  (in  this  animal)  still  it  served  a  useful  pur- 
pose in  that  the  stimuli  were  conducted  more  quickly  and  that 
therefore  the  threshold  of  response  was  greatly  lowered.  In  the 
earthworm,  which  is  composed  of  segments,  each  segment  has  its 
own  special  nerve  supply.  Forward  motion  in  this  animal  is  due 
to  the  alternate  action  of  the  longitudinal  and  the  circular  mus- 
cles. Friedlander  found  that  removal  of  its  central  nervous  sys- 
tem had  no  effect  on  the  coordination  of  progressive  motion. 
This  is  explained  by  Loeb,  who  says  that  when  the  forward  piece 
is  elongated  and  attempts  to  shorten  itself  by  contraction  of  the 
longitudinal  muscles,  the  skin  of  the  aboral  piece  is  stretched  and 
that  this  stretching  produces  a  stimulus  to  the  longitudinal  mus- 
cles of  the  posterior  piece  which  then  contracts  and  causes  the 
animal  to  move  forward.  Thus  at  this  stage  of  biologic  advance- 
ment, motion  is  not  the  result  of  sensation,  but  is  only  a  reflex  of 
a  very  simple  nature.  In  animals  of  a  higher  order  the  same 
stimulus  exists,  but  the  stimulus  of  origin  is  in  some  cases  far 


REACTION    or    ANIMALS    TO    PAIN  3' 

removed  from  the  stimulus  of  effect.  The  conduction  from  place 
of  origin  to  point  of  effect  being  through  nerve  paths,  the  motion 
is  still  the  result  of  a  reflex,  and  this  reflex  either  causes  the  ani- 
mal to  move  to  or  draw  away  from  the  source  of  the  stimulus 
either  as  it  is  beneficial  or  destructive  to  its  economy.  When  it 
does  so  withdraw  or  when  it  responds  to  excitor  stimuli  by  rapid 
and  irregular  motion,  are  these  an  indication  of  a  disagreeable 
sensation  or  of  pain  ? 

Reaction  of  Animals  to  Pain.— Many  have  assigned  to  the 
lower  organisms  the  same  pain  sensation  as  that  possessed  by  man. 
The  reason  assigTied  for  this  hypothesis  is  that  reactions  take 
place  to  injurious  stimulation,  by  various  reflex  movements,  and 
that  these  reflex  movements  are  the  motor  manifestation  of  pain. 
This  interpretation  is  contested  by  IS^orman  ("American  Journal 
of  Physiology,"  Vol.  Ill,  p.  271,  1899),  who  states  that  in  many 
animals,  ranging  from  the  simple  worm  to  the  higher  vertebrates, 
such  as  fish,  he  has  cut  off  segments  of  the  body  and  otherwise 
insulted  the  integrity  of  the  structure,  without,  in  some  instances, 
producing  any  movement  at  all,  or,  if  movement  occurred,  with- 
out producing  any  which  was  greater  than  that  caused  by  ordinary 
and  slight  stimuli.  He  maintains  that  the  movement  of  an  ani- 
mal is  not  due  to  impulses  caused  by  the  sensation  which  we  desig- 
nate as  pain.  Should  excessive  reflex  movements  be  produced, 
they  are  the  result  of  an  excess  of  stimuli,  not  necessarily  destruc- 
tive. His  experiments  were  varied  and  numerous.  In  one  in- 
stance, he  cut  an  earthworm  in  two ;  and  while  the  posterior  part 
performed  very  rapid  twisting  and  squirming  movements,  the 
anterior  half  simply  elongated  and  went  on  crawling,  the  same  as 
before  the  experiment.  Is  it  possible  that  pain  would  be  felt  in 
the  posterior  part,  and  that  the  anterior  segment,  in  which  the 
main  ganglia  are  located,  would  be  free  of  pain  ?  l^orman 
elaborated  his  experiments  further.  He  cut  in  half  a  leech,  which 
was  swimming  in  the  water,  and  observed  that  both  segments 
continued  their  motion  without  interruption.  Starfish  and  crabs, 
as  well,  showed  no  reaction  to  division.  He  cut  away  the  posterior 
part  of  the  abdomen  of  a  bee,  while  it  was  engaged  in  sucking 


4  GENERAL   CONSIDERATION  OF  SENSATION 

honey,  without  any  interruption  to  its  activity.  He  also  men- 
tions the  fact  that  sharks  may  be  cut  and  operated  upon  without 
the  slightest  movement  on  their  part.  Experiments  of  this  nature 
tend  to  show  that  one  must  ascend  rather  high  in  the  vertebrate 
scale  before  true  pain  phenomena  make  their  appearance.  In 
fact,  it  is  only  in  mammals  that  this  sensation  is  developed  to  its 
highest  degree.  In  our  study  of  pain,  therefore,  we  must  bear  in 
mind  that  motor  response  to  an  irritant  is  not  always  an  indi- 
cation of  pain,  but  is  only  a  reaction  to  stimuli  (not  necessarily 
sensory).  However,  before  proceeding  further  in  our  considera- 
tion of  pain  phenomena  we  shall  study  sensation  and  its  attributes. 
General  Consideration  of  Sensation.^ — Sensation  itself  is 
the  perception  of  an  impression  conveyed  to  the  brain  as  the  result 
of  the  activity  of  some  peripheral  sense-organ.  These  sense-organs 
may  give  rise  to  both  subjective  and  objective  sensations.  Sub- 
jective sensation  is  the  result  of  activity  of  those  forces  of  the 
body  which  are  concerned  with  its  integrity  and  well-being.  It 
gives  rise  to  hunger,  satiety,  nausea,  thirst,  physical  or  mental 
depression,  or  exhilaration,  joint  sensation,  and  the  like,  and  may 
be  called  an  organo-protective  sensation.  It  also  produces  the 
feeling  of  fatigue  and  exhaustion.  Objective  sensations  primarily 
depend,  for  their  perception,  upon  the  presence  of  external  re- 
ceptors, such  as  those  of  sight,  touch,  smell,  hearing,  taste,  tem- 
perature, etc.  Therefore,  in  order  to  have  sensation,  that  is,  to 
be  capable  of  perceiving  and  interpreting  stimuli,  and  of  classi- 
fying them  under  certain  empirical  divisions  as  belonging  to  one 
domain  or  another  of  feeling,  it  is  first  necessary  that  our  sense- 
receptive  organs  be  intact,  the  sense-conveying  organs  normal,  the 
sense-interpreting  centers  active  and  the  associative  memory  cen- 
ter (consciousness)  intact.  Should  the  latter  be  disturbed,  as  oc- 
curs during  certain  mental  diseases,  anesthesia,  etc.,  sensory  stim- 
uli, irrespective  of  their  character,  either  will  fail  to  be  perceived, 

'  Feeling  is  the  impression  which  sensory  stimuli  arouse  in  consciousness.  An 
example  from  IMeyer  is  that  we  perceive  that  ice  gives  rise  to  a  cold  sensation,  which 
in  turn  causes  an  unpleasant  feeling.  To  be  properly  influenced,  i.  e.,  to  be  influenced 
so  that  the  resulting  feeling  properly  represents  the  combined  results  of  the  sense 
perceptions,  requires  that  one  be  in  a  proper  receptive  state,  i.  e.,  anger  or  disagree- 
able emotions  destroy  the  pleasure  created  by  pleasing  sounds  or  beautiful  combina- 
tions of  color. 


GENERAL   CONSIDERATION   OF  SENSATION  5 

or,  if  they  are,  will  be  greatly  modified.  Since  we  speak  of  con- 
sciousness it  may  be  well  to  briefly  consider  it.  It  has  been  de- 
fined as  the  ability,  power,  faculty,  or  mental  state  of  being  aware 
of  one's  own  existence,  thoughts,  feelings,  actions  and  sensations, 
whether  intellectual,  moral  or  physical  (Sudduth,  472),  and  must 
be  present  to  take  up  and  correlate  the  different  stimuli  reaching 
the  brain  from  the  periphery. 

Consciousness  has  been  divided  into  two  classes:  (a)  subjective 
and  (b)  objective.  Subjective  consciousness  tells  us  of  things 
which  originate  in  the  mind  (we  shall  have  occasion  to  use  this 
concept  later  in  our  study  of  hysteria).  Objective  consciousness 
tells  us  of  things  perceived  through  the  senses. 

Of  the  senses  we  distinguish  two  varieties,  the  internal  and 
the  external.  The  internal  senses  are  those  which  are  concerned 
with  the  well-being  of  the  organism,  and  the  relation  of  the  dif- 
ferent parts,  one  to  another.  They  include  muscle  sense,  joint 
sense,  hunger  sense,  etc.  The  external  senses  are  those  which 
are  concerned  with  the  interpretation  of  external  objects,  and  in- 
clude, generally  speaking,  touch,  smell,  sight,  hearing,  taste,  mus- 
cular and  temperature  sense.  Each  of  these  senses  has  a  complete 
nerve  apparatus  of  its  own,  consisting  of  sense-receptive,  sense- 
conveying,  and  sense-perceptive  organs.  The  sense-receptive  or- 
gans are  the  terminal  filaments  of  the  sensory  nerves.  The  sense- 
conveying  organs  are  the  axis  cylinders  of  the  sensory  ganglia  cells 
(the  nerves)  and  the  sense-perceptive  organs  are  the  sensory  cor- 
tical cells. 

We  now  have  the  apparatus;  all  that  is  lacking  is  the  force. 
The  question  now  arises,  what  is  this  force,  and  what  varieties  of 
stimuli  produce  the  changes  which  give  rise  to  sensation  ?  The  two 
most  prominent  hypotheses  are  that  the  stimulus  is  of  a  chemical 
or  electrical  nature  or  is  a  mechanical  force  in  the  form  of  vibra- 
tion. The  chemical  hypothesis  is  that  the  external  stimuli  produce 
some  chemical  change  in  the  cell,  which  reaction  is  propagated 
into  other  adjacent  cells  until  it  reaches  the  perceptive  center. 
Engelman  (377)  advances  the  idea  that  the  impulse  which  cre- 
ates sensation  is  of  an  electrical  nature,  but  does  not  exactly  de- 


6  GENERAL  CONSIDERATION  OF  SENSATION 

fine  what  he  means  by  electrical  nature.  By  many,  however,  it 
is  held  that  all  sensation  is  the  appreciation  of  arrested  motion 
(vibration),  this  motion  being  the  result  of  a  mechanical,  a  chem- 
ical or  an  electrical  contact.  It  is  the  motion  of  the  ether  mole- 
cules upon  the  retina  which  produces  the  "formation  or  decom- 
position of  certain  substances  and  it  is  the  chemical  processes  of 
the  formation  and  decomposition  of  these  substances  which  deter- 
mine light  and  color  sensations"  (Loeb,  104  C,  p.  291);  the  mo- 
tion of  the  air  molecules  upon  the  drum  membrane  of  the  ear 
which  "causes  vibration  in  endings  of  the  auditory  nerve  by  which 
new  molecules  are  brought  into  contact  with  each  other  and 
sound  is  produced"  (Loeb);  the  impact  of  the  odoriferous  parti- 
cles upon  the  olfactory  nerve  terminals  in  the  mucous  membrane 
of  the  nose  which  creates  smell  (chemical  action).  ,For  taste,  it  is 
essential  that  the  sapid  substance  shall  come  in  contact  with  the 
taste-buds  of  the  tongue  (chemical  action);  for  touch,  that  matter 
must  come  in  contact  with  the  nerve  terminations  in  the  skin.  Thus 
we  see  that  all  sensation  depends  upon  contact,  and  that  contact 
gives  rise  to  motion.  This  motion  is  in  the  form  of  vibration 
(molecular),  and  the  sensation  produced  depends  upon  the  sense- 
organ  against  which  the  vibration  impinges.  Each  terminal  sense- 
organ  takes  up  only  the  vibrations  produced  in  a  particular  me- 
dium. For  instance,  in  the  normal  state,  sound  is  perceived  only 
when  the  air  is  in  vibration  against  the  cochlear  apparatus;  light 
depends  wholl}^  upon  the  vibration  of  the  ether  upon  the  retina; 
smell  upon  the  impingement  of  minute  physical  particles  upon 
the  olfactory  terminals,  etc.  It  is  also  of  great  interest  to  know 
that  the  sense  perception  of  these  organs  in  man  is  limited  to  the 
perception  of  vibrations  which  lie  within  certain  limits.  For 
example,  the  human  ear  is  unable  to  hear  if  the  vibration  is 
below  two  per  second,  or  greater  than  thirty-three  thousand  per 
second.  Thus  man  is  unable  to  hear  the  calling  of  a  whale,  be- 
cause the  tone  of  the  whale's  voice  vibrates  only  two  per  second; 
as  he  also  frequently  is  unable  to  hear  the  humming  of  a  swarm 
of  gnats,  a  sound  which  is  produced  by  a  vibration  of  about  thirty- 
five  thousand  per  second. 


SENSORY  PERCEPTION   AND  THE   SENSE-ORGANS  7 

The  adequate  stimulus,  according  to  Loeb,  loc.  cit.,  p.  181,  is 
transmitted  from  the  receiving  station  to  the  perceiving  station 
by  means  of  ions,  the  exact  nature  of  which  is  not  known.  He 
claims  that  whenever  the  progress  of  the  ions  is  blocked  in  the 
central  nervous  system  an  increase  in  their  concentration  will 
occur,  and  that  this  must  be  followed  by  physical  or  chemical 
alterations  of  the  colloids.  It  may  also  happen  that  too  fre- 
quently repeated  stimuli  will  leave  a  disorganizing  action  on  the 
colloids  and  that  this  disorganization  is  interpreted  by  the  organ- 
ism as  pain. 

Properties  of  Sensation. — Sensation  possesses  the  following 
properties:   quality,  intensity,  and  duration. 

(1)  Quality  gives  us  an  idea  as  to  the  cause  of  the  sensation. 
For  instance,  the  quality  of  the  sensation  of  sound  is  entirely  dif- 
ferent from  that  of  the  sensation  of  taste,  and  it  is  this  difference 
which  enables  us  to  correctly  determine  the  source  of  origin 
(whether  from  a  peripheral  sense-organ  of  taste,  hearing,  smell, 
etc.).  It  also  enables  one  to  distinguish  variations  in  the  same 
sensation. 

(2)  Intensity  enables  us  to  distinguish  differences  in  the 
strength  of  stimuli  producing  the  same  sensation,  and  indicates, 
also,  the  receptive  state  of  the  organism  to  the  sensation.  At  cer- 
tain times  pain  is  much  more  acutely  felt.  This  is  due  to  the 
fact  that  at  these  times  the  organism  is  weaker,  being  either  re- 
duced by  exhaustion  or  disease,  and  therefore  it  is  more  acutely 
affected  by  all  irritative  stimuli. 

(3)  Duration  of  a  sensation  depends,  first,  upon  the  inten- 
sity, and  second,  on  the  rapidity  of  the  impulse.  If  the  impulse  is 
very  intense,  the  sensation  in  the  sense-perceiving  centers  persists 
for  some  time  after  the  stimulus  has  ceased.  For  example,  if  a 
bright  light  is  placed  before  the  eyes,  the  sensation  of  light  per- 
sists for  some  time  after  the  light  stimulus  ha-s  been  removed;  also 
if  we  gaze  at  a  bright  light  and  then  close  the  eyes,  the  sensation 
of  light  still  continues  for  a  few  seconds.  The  rapidity  of  the 
repetition  of  stimuli  also  influences  the  duration  of  the  sensation. 
If  the  stimulus  is  repeated  too  frecjuently,  we  find  that  a  continu- 


8  GENERAL  CONSIDERATION   OF  SENSATION 

ous  instead  of  an  interrupted  sensation  is  felt.  This  is  due  to  the 
fact  that  the  sense  perception  of  all  stimuli  persists  for  a  short 
time  after  the  stimulus  has  ceased  to  exist.  Thus,  if  the  stimuli 
follow  each  other  at  short  intervals,  the  sensation  is  that  of  a  con- 
tinuous stimulation.  At  times,  remissions  in  sensation  occur,  and 
are  due  to  fatigue  of  the  central  sense-perceiving  center. 

Centers  for  Sensory  Perception  and  the  Sense-Organs. — It 
has  been  observed  by  Goltz,  H.  Munk  and  others  (Tigerstedt's 
"Physiology,"  p.  651),  that  in  the  dog  the  destruction  and 
removal  of  the  motor  region  and  the  cortical  layers  adjacent 
thereto  cause  a  variety  of  derangements  of  sensation  and  of  mo- 
tion. These  cortical  layers,  then,  must  in  some  manner  be  con- 
cerned with  the  perception  of  sensation.  It  has  been  found  that  if 
the  entire  cortical  area  for  the  posterior  extremity  is  removed  the 
muscles  of  the  opposite  leg  can  no  longer  execute  finely  graded 
movements;  that  for  some  days  after  the  operation  a  complete 
insensibility  in  this  extremity  exists;  and  that  a  certain  blunt- 
ness  of  sensibility  becomes  permanent. 

With  still  more  extensive  destruction,  the  finer  movements  of 
the  hand  and  foot  are  permanently  arrested  in  the  monkey, 
and  for  some  time  after  the  operation  the  sensitiveness  of  the 
paws  is  somewhat  reduced,  so  that  the  animal  reacts  only  to  very 
painful  stimuli.  In  fact,  the  sensitiveness  of  the  hand  and  foot 
becomes  permanently  so  slight  that  a  severe  pinch  produces  no 
reaction  at  all  (Mott).  On  the  other  hand,  Schaffer  has  found 
that  a  monkey  which  does  not  react  at  all  to  a  painful  pinch  im- 
mediately notices  a  slight  tactile  stimulus  applied  to  the  para- 
lyzed extremity.  The  monkey  from  which  Goltz  had  removed 
the  entire  motor  region  of  the  left  hemisphere  took  no  notice  of 
the  gentle  tactile  stimuli  applied  to  the  right  extremity. 
Stronger  pressure  stimuli  were  always  felt.  INIotor  sensations 
were  also  somewhat  diminished. 

From  this  it  will  be  observed  that  generally,  except  in  the 
case  mentioned  by  Schaffer,  in  which  pain  sensation  was  lost 
but  tactile  sensation  was  present,  it  will  be  found  that,  in  case 
of  destruction  of  the  motor  area,  the  sensation  in  the  skin  over 


General  Sensation  Touch 


Vision 


Hearing 

Fig.  1. — Right  Cerebral  Hemisphere  Seen  from  the  Outside. 


General  Sensatiorl 


Vision 


Smell 


Fig.  2. — Inner  Surface  of  Right  Cerebral  Hemisphere. 
Figures  1  and  2  show  the  areas  of  sensory  distribution  according  to  Tiger- 
stedt  (p.  654),  modified  from  Flechsig.     Dots  indicate  sensory  areas. 
Areas  where  dots  are  thickest  are  the  regions  where  most  of  the  sensory 
pathways  end. 


10  GENERAL  CONSIDERATION   OF  SENSATION 

the  paralyzed  part  will  also  be  reduced  for  touch,  but  present 
for  pain.  This  might  be  accounted  for  on  three  hypotheses:  (1) 
that  the  impulse  which  would  produce  pain  is  so  intense  that  it 
spreads  over  a  considerable  area  of  the  cortex,  and  is  communi- 
cated to  parts  which  are  not  destroyed  and  which  still  have  the 
power  of  pain  perception;  or  (2)  that,  owing  to  the  strength 
and  volume  of  the  impulse,  it  is  transmitted  to  the  cortical  area 
in  the  opposite  hemisphere,  and  is  there  perceived;  (3)  that 
the  center  for  pain  sensation  is  not  in  the  cortex,  but  lies  proximr.l 
to  it  in  one  of  the  forwarding  structures  of  the  sensory  apparatus^, 
namely,  in  the  optic  thalamus.  The  first  supposition  gives  weight 
to  the  argument  that  it  is  the  extent  of  the  cortical  reaction  which 
produces  the  relative  sensations,  either  of  touch  or  of  pain,  a  small 
area  giving  rise  only  to  touch,  a  large  area  to  pain.  This  possibly 
can  be  explained  from  the  inhibitory  action  of  the  cortex,  the 
destruction  of  a  small  area  being  not  sufficient  to  abolish  the  in- 
hibitory impulses  sent  from  the  cortex  to  the  optic  thalamus  and 
their  acting  as  controls  over  the  sensory  perceptions. 

It  has  been  found  that  general  sensation  and  touch  are  lost 
by  destruction  of  the  central  and  parietal  convolutions,  paracen- 
tral lobules,  and  possibly  the  posterior  part  of  the  frontal  convo- 
lutions, and  that,  for  the  most  part,  the  sensory  area  consists  of 
post  central  and  parietal  convolutions  (Leszynsky,  498;  May, 
397,  p.  793). 

Many  sensory  fibers  enter  the  post  central  convolution.  Some 
also  enter  the  precentral  convolution.  The  first  and  second  frontal 
convolutions  also  receive  some  fibers;  they  chiefly  are,  however, 
sensory  fibers  connected  with  the  cerebellar  system. 

Upon  destruction  of  these  areas,  the  different  sensations  are 
differently  affected,  namely:  (1)  pain  sensations  suffer  least, 
because  a  wider  area  is  required  for  their  destruction;  (2)  pres- 
sure and  temperature  sensations  are  somewhat  reduced,  but  by 
no  means  abolished;  (3)  power  of  localization  is  profoundly 
affected;  (4)  motor  sensations  are  much  disturbed. 

The  areas  for  sensation  are  probably  bilateral  in  their  loca- 
tion.    Mills  claims  that  they  are  also  found  in  the  limbic  and 


SENSE   PERCEPTIVE   ORGANS  11 

quadrate  lobes.  While  Dana  admits  that  this  is  possible,  he 
also  holds  that  the  motor  areas  are  also  sensory  (Church  and 
Peterson,  506,  p.  307).  The  sensorimotor  area,  in  the  optic 
thalamus  (the  so-called  associative  memory  center  of  Loeb),  is 
probably  a  depot  for  memory  of  sensation  as  it  passes  on  its  way 
to  higher  centers,  in  the  limbic  or  c^uadrate  lobes. 

According  to  Horsley  (ibid.,  p.  162),  the  different  cell  areas 
for  motion  and  sensation  are  superimposed  in  strata.  ^Nlost  super- 
ficially the  tactile  sense,  then  the  muscular  sense,  and  finally  the 
pure  motor  sense  elements  are  found.  It  appears  that  in  these 
areas  the  granular  cells  are  the  active  agents  in  sensory  percep- 
tion, since  lesions  in  this  cell  layer  cause  disturbances  of  touch, 
pressure,  localization,  muscular  sensibility  (sense  of  passive  posi- 
tion and  of  movement),  and,  less  frequently,  of  pain  and  tem- 
perature. This  disturbance  occurs  in  the  opposite  side  of  the 
body,  and,  when  a  limb  is  involved,  the  sensation  is  first  lost  in, 
and  is  last  to  return  to,  the  distal  portion  and  outer  margin  (W. 
Page,  May,  397,  p.  796). 

The  small  pyramidal  cell  layer  may  also  be  concerned  indi- 
rectly in  pain  production,  since  these  cells  are  atrophied  in 
dementia,  and  may,  therefore,  be  indirectly  associated  with  sensi- 
bility; because  it  has  been  found  that  sensibility  varies  almost 
directly  in  proportion  to  the  mental  development  of  the  individual, 
and  that  the  pyramidal  cells  vary  directly  in  proportion  to  the 
mentality. 

It  has  also  been  claimed  that  the  cerebellum  is  the  seat  of  all 
pleasure  and  pain  activities  (F.  Courmont,  "Le  Cervelet  et  ses 
Fonctions"),  and  also  of  those  connected  with  the  emotions 
(Marshall,  p.  25).  ^Modern  anatomical  research,  however,  has 
shown  that  the  cerebellum  is  the  chief  central  organ  for  the  senses 
of  equilibrium,  muscle  tonus,  and  orientation  in  space.  And  al- 
though it  is  preeminently  a  sensory  organ,  the  cortex  being  a 
sensory  cortex,  it  is  not  such  for  pain,  for  light  touch,  heat,  or 
cold. 

Sense  Perceptive  Organs. — Recently  the  sense-organs,  the 
stimulation  of  which  causes  sensation,   have  been  divided  into 


12  GENERAL  CONSIDERATION   OF  SENSATION 

three  classes:  (1)  the  visceral  sense-organs  of  the  internal  organs 
and  their  derivatives,  (2)  the  extroceptor,  or  somatic,  sense-organs, 
which  receive  the  impressions  from  the  outer  world,  and  (3)  the 
proprioceptors,  which  receive  impressions  from  the  muscles,  ten- 
dons, etc.,  and  report  to  the  sensory  area  the  exact  position  of  the 
body  and  the  relationship  of  parts  to  each  other. 

The  researches  of  Head,  Holmes,  and  Sherrington  have  served 
to  show  that  the  constituents  of  sensation  are  extremely  complex. 
So  far  as  the  visceral  receptors  are  concerned,  we  know  very  little 
about  them.  There  are  chemical,  touch,  heat,  and  cold  receptors, 
and  undoubtedly  receptors  which  have  to  do  with  the  forces  of 
gravity.  Most  of  these  receptors  Head  has  placed  within  his  pro- 
topathic  system.  They  belong,  phylogenetically  speaking,  to  old 
systems;  are  almost  automatic,  and  for  the  most  part  are  passed 
over  to  the  autonomic  sympathetic  nervous  system.  Their  spinal 
representations  are  present  largely  in  the  lateral  processes  of  the 
cord.     Their  central  paths  are  not  as  yet  definitely  determined. 

The  extroceptor  or  somatic  sense  organs  are  divided  b}-  Head 
into  the  epicritic  and  protopathic  systems.  The  ability  to  dis- 
tinguish light  touch  (cotton  wool),  two  points  of  a  compass  (at 
small  intervals  varying  with  the  part),  and  to  discriminate  slight 
variations  in  temperature,  are  held  by  Head  to  be  specific  and  in- 
dividual entities.  Together  they  constitute  his  epicritic  system. 
Their  spinal,  medullary,  thalamic,  and  cortical  distributions  have 
been  fairly  well  defined.  To  the  protopathic  system  on  the 
other  hand  belong  the  faculties  to  distinguish  ordinary  touch,  deep 
pressure,  extremes  of  heat  and  cold.  Finally,  according  to  Sher- 
rington, there  exists  another  system,  the  proprioceptive.  Its  re- 
ceptors are  found  in  many  places  in  the  body,  chiefly  in  the  ten- 
dons, muscles  and  bones,  and  also  most  characteristically  in  the 
labyrinth.  Its  chief  sensations  are  those  connected  with  the 
orientation  of  the  body  in  space;  the  vestibular  nerve  being 
its  chief  cephalic  ganglion  and  the  cerebellum  its  chief  central 
organ. 

Stimuli. — The  stimuli  necessary  to  produce  a  sensory-reaction 
may  be  mechanical,  chemical,  thermal  or  electrical.    Any  of  these. 


INTERPRETATION   OF  SENSATION  13 

when  applied  in  normal  quantity,  and  with  normal  force,  produces 
a  normal  reaction;  but  when  applied  with  excessive  intensity,  all 
are  capable  of  stimulating  the  specific  pain  receptors. 

Interpretation  of  Sensation. — If  we  consider  for  a  moment 
the  embryological  development  of  the  human  body,  we  find  that 
the  external  organs  of  sensation  develop  pari  passu  with  the  in- 
ternal organs,  but  that  the  external  ones  are  practically  without 
function  until  the  fetus  is  born.  During  the  period  of  intra- 
uterine existence,  the  external  senses  are  lying  dormant,  but  as 
soon  as  the  fetus  is  born,  and  feels  the  touch  of  air  upon  its  sur- 
face, it  has  entered  upon  a  new  life,  and  one  vast  complex  of 
sensations  reaches  it  from  every  side.  Embryologically  the  vestib- 
ular system  develops  very  early. 

These  sensations  are  for  three  purposes:  (1)  to  provide  pro- 
tection for  the  organism;  (2)  to  provide  for  its  development;  and 
(3)  to  provide  for  its  reproduction.  We  find  that  in  general 
everything  which  reacts  unfavorably  to  the  organism  causes  dis- 
tasteful and  disagreeable  sensations.  These,  when  of  a  peculiar 
quality  and  intensity,  give  rise  to  the  sensation  which  we  term 
pain.  It  is  also  found  that  everything  which  acts  or  aids  in  the 
growth,  development  and  reproduction  of  the  organism  causes 
pleasure.  Between  the  two  extremes  of  pain  and  pleasure  there 
exists  a  neutral  state,  where,  because  of  the  weakness  of  sensory 
stimulation  or  perception,  a  state  neither  of  pleasure  nor  of  pain 
is  produced.  This  we  term  the  state  of  indifference.  Therefore, 
we  may  be  said  to  have  three  states  of  sensory  mental  activities, 
namely,  pain,  indifference,  and  pleasure. 

Definition  of  Pain. — Pain  is  distinctly  a  mental  interpre- 
tation, and  cannot  be  strictly  defined.  It  is  the  interpretation  of 
some  abnormal  and  generally  harmful  process  which  is  occurring 
in  the  organism.  It  cannot  be  classed  as  a  sensation,  but  rather 
is  the  result  of  the  perception  and  interpretation  of  sensation  by 
the  mind.  Our  consideration  of  pain  will  naturally  lead  us  into 
a  discussion  of  its  antithesis,  pleasure,  since  the  two  are  inti- 
mately connected  in  their  perception  and  in  their  interpretation. 
Both  are  the  result  of  mental  activity. 


14  GENERAL  CONSIDERATION   OF  SENSATION 

Mental  Activity. — According  to  many  authors,  three  divi- 
sions of  mental  activity  have  been  assumed:  intellect,  or  the 
faculty  of  thought;  sensibility,  or  the  faculty  of  feeling,  and  voli- 
tion, or  the  faculty  of  voluntary  action.  This  is  manifestly  a 
purely  artificial  division.  While  we  are  primarily  interested  with 
the  second  division,  it  is  my  purpose  to  show  that  it  is  intimately 
bound  up  with  the  first  (intellect).  I  shall  also  point  out  that  the 
intellect  can,  by  the  exercise  of  memory,  recall  to  mind  the  ob- 
jective sensations  classified  as  pain,  and,  by  making  them  perti- 
nent to  the  moment,  cause  them  to  appear  real,  as  if  experienced 
at  the  time.  In  other  words,  intellect  is  able  to  produce,  without 
any  objective  means,  the  sensation  of  pain.  This  class  of  pain- 
sensation,  which  seems  to  appear  without  any  definite  causative 
factor,  is  frequently  called  subjective  pain. 

The  crudest  mental  impressions  consist  of  the  primary  sensa- 
tions of  touch,  sight,  hearing,  taste,  smell,  and  temperature,  which 
are  objective,  and  muscle  sense,  joint  sense,  hunger  sense,  etc., 
which  are  subjective.  These,  when  carried  to  and  interpreted  by 
the  brain,  result  either  in  pleasure  sensation,  neutrality,  or  pain; 
and  as  a  result  of  these  mental  interpretations  there  arise  certain 
mental  states,  such  as  joy,  sadness,  pleasure,  and  happiness,  which 
in  turn  may  give  rise  to  mental  activities,  such  as  anger  or  its 
converse. 

Mental  States. — I  do  not  mean  to  say  that  all  sensation 
must  definitely  be  interpreted  either  as  painful  or  as  pleasant,  in- 
asmuch as  there  are  sensations  which  are  neither  painful  nor 
pleasant.  These  are  referred  to  as  neutral  sensations.  For  in- 
stance, the  sight  of  a  tree  may  be  neither  pleasant  nor  painful^ 
but  the  recollection  of  certain  facts  associated  with  that  particu- 
lar tree  may  recall,  at  the  sight  of  it,  certain  thoughts  that  induce 
a  painful  or  rather  unhappy  emotion;  and  here  it  is  well  to  dif- 
ferentiate emotion,  which  is  a  mental  state,  from  pleasure-sense 
or  from  pain,  which  are  but  sensations.  Ideas  or  thoughts  may 
give  us  pleasure,  but  it  requires  an  external  stimulus  to  arouse 
the  pleasant  sensation  that  may  accompany  thought,  such  as  is 
found  in  reading,  in  listening  to  sounds  which  are  pleasant  when 


INTERPRETATION   OF  SENSATION  15 

grouped  in  the  form  of  harmony,  in  hearing  beautiful  ideas  well 
expressed,  or  in  seeing  wondrous  productions  of  blended  colors 
in  the  form  of  a  beautiful  landscape.  Therefore,  the  use  of  the 
word  pleasure  should  be  restricted,  I  think,  to  the  mental  state 
following  upon  pleasant  or  agreeable  sensations,  which,  in  turn, 
should  be  called  pleasure-sensations.  Thus  we  have  the  emotional 
condition  of  pleasure  and  of  its  converse,  displeasure. 

Mental  Resultants. — From  every  mental  state,  certain  de- 
rivatives arise;  for  instance,  anger  is  often  evolved  from  dis- 
pleasure, while  pleasure  gives  rise  to  elation.  It  is  the  affective 
state  which  we  are  in  that  colors  our  perception  and  guides  our 
acts;  and  it  is  particularly  fitting,  in  this  connection,  that  physi- 
cians should  bear  in  mind  that  the  fundamental  cause  of  an  ill- 
behaved,  crabbed  disposition  very  often  is  to  be  found  in  the 
elementary  sensations  coming  from  the  periphery,  acting  as  ex- 
citors  to  a  possibly  already  overwrought  and  abnormal  nervous 
system.  How  easy  it  is,  on  this  hypothesis,  to  account  for  the 
sour  and  surly  disposition  of  the  dyspeptic,  or  the  forbidding  as- 
pect of  the  chronic  sufferer!  They  are  worthy  of  our  kindest  con- 
sideration, for  their  disposition  and  their  evil  manners  are  often 
due  to  causes  over  which  they  have  little  control. 

Relation  of  Pain  and  Pleasure  to  Mental  States. — Ac- 
cording to  Marshall,  pleasures  and  pains  are  but  differential  quali- 
ties of  all  mental  states.  To  this  I  must  take  exception,  for,  to 
my  mind,  they  are  but  interpretations  of  sensations  which  are 
perceived  as  arising  in  the  periphery. 

It  would  seem  more  fitting  that  pleasure,  when  applied  to  sense 
perception,  should  be  spoken  of  as  pleasure-sensation.  For  in- 
stance, a  cool  bath  taken  on  a  warm  day  gives  rise  to  a  pleasant 
sensation  and  at  the  same  time  produces  pleasure;  but  thoughts 
of  an  absent  one,  or  of  some  joyous  past  event,  may  give  pleasure, 
while  at  the  same  time  we  have  no  pleasant  sensation. 

Next  it  behooves  us  to  ask,  can  both  pleasure-sensation  and 
pain  be  perceived  at  the  same  time,  and,  if  they  are  not  perceived 
and  factors  which  ordinarily  produce  them  are  present,  is  their 
non-perception  due  to  the  fact  that  they  neutralize  each  other? 


16  GENERAL   CONSIDERATION  OF  SENSATION 

It  is  inconceivable  that  two  such  opposites  as  these  could  exist  in 
consciousness  at  the  same  time;  and  it  is  entirely  improbable  that, 
should  such  a  state  exist,  their  contra-action  would  produce  a  con- 
dition of  neutrality,  which  is  the  result  of  two  active,  equal  and 
opposing  forces.  For  instance,  the  distress  which  comes  from  an 
ulcerated  stomach  or  an  irritated  sore  cannot  be  neutralized  by 
the  physical  pleasure  derived  from  epidermic  sources.  We  experi- 
ence either  pleasure  or  pain;  there  is  no  halfway  stop  where  the 
one  counteracts  the  other,  giving  rise  to  a  state  neither  of  pleasure 
nor  of  pain,  but  of  neutrality.  Yet,  in  some  cases  a  transition 
from  pleasure  to  pain-sensation  may  occur,  for  it  is  found  that 
sensations  which  ordinarily  are  interpreted  as  pleasant  may,  from 
frequent  repetition  and  excessive  stimulation,  become  painful,  as 
in  pericementitis,  in  which  at  first  a  pleasant  sensation  is  pro- 
duced on  lightly  pressing  the  teeth  together,  but  which,  if  the 
pressure  is  continued  or  increased,  results  in  pain.  Another  ex- 
ample is  priapism,  in  which  the  distention,  which  at  first  is  pleas- 
ant, if  continued,  soon  becomes  painful.  Gentle  friction  over  the 
body,  especially  over  the  nape  of  the  neck,  is  pleasant  (to  most 
people);  yet,  if  the  friction  becomes  excessive,  and  the  nerve- 
endings  are  irritated,  the  pleasant  sensation  is  transformed  into 
a  painful  one.  Again,  a  harmonious  play  of  colors  is  soothing  and 
pleasant  to  the  eye;  but  let  the  colors  be  exceedingly  brilliant,  the 
pleasant  sensation  is  transformed  into  a  disagreeable  and  painful 
one.  Another  example  may  be  deduced  from  the  sense  of  hear- 
ing. We  all  know  how  pleasant  to  the  ear  are  the  tones  of  a  harp; 
but  change  them  into  the  shrill  notes  of  the  siren  and  we  almost 
shriek  with  pain,  or  rather  let  us  say  distress.  Yet,  if  now  we 
modify  the  vibrations  and  reduce  them  in  number,  the  distress 
disappears;  and  the  sound,  while  neither  painful,  nor  pleasant, 
may  become  pleasant  if  we  place  among  its  components  some  half 
tones  which  increase  the  fullness  and  volume.  These  are  examples 
of  sensations  changing  from  pleasant  to  painful,  and  then  back 
again  from  painful  to  pleasant.  The  changes  which  bring  this 
about  are  the  result  of  variations  in  the  force  and  rapidity  of  the 
impulses  impinging  on  the  nerve  ternainals, 


INTERPRETATION   OF  SENSATION  17 

The  change  from  a  neutral  state  to  one  of  pain  may  not  be 
acute,  but  rather  a  gradual  increase  in  unpleasant  sensation  un- 
til the  threshold  for  pain  perception  is  past  and  the  patient  has  the 
sensation  of  pain.  This  transition  from  pleasure  sensation  to 
that  of  pain  occurs  on  the  application  of  heat  or  cold  or  on  the 
application  of  pressure  to  a  part.  In  the  latter  the  pressure  may 
at  first  be  so  light  that  it  is  not  perceived;  then  it  may  become 
stronger  and  be  felt  as  touch;  then  again  stronger  and  be  felt  as  a 
definite  sensation  of  pressure.  Finally  it  may  become  still  stronger 
and  then  be  felt  as  pain. 

Certain  laws  have  been  deduced  from  the  transitional  inter- 
pretation of  impulses  from  pleasure  to  pain,  of  which  the  two 
following  are  taken  from  IMoher  ("Psychology,"  p.  225),  who 
says  that: 

(1)  Pleasure  is  an  accompaniment  of  the  spontaneous  and 
healthy  activity  of  our  faculties,  and  pain  is  either  the  result  of 
their  restraint  or  of  their  excessive  exercise, 

(2)  Pleasure  increases  with  increasing  vigor  in  the  opera- 
tion, up  to  a  certain  normal  medium  degree  of  exertion,  and  pro- 
gressively diminishes  after  that  stage  is  passed.  Farther  on,  pleas- 
ure disappears  altogether,  and  beyond  this  line  pain  takes  its  place. 

Whether  this  interpretation  is  correct  is  not  yet  apparent.  If 
the  receptors  for  light  and  sound,  for  example,  have  specific  pain 
receptors,  which  have  a  definite  threshold  value  and  only  react 
when  the  intensity  of  the  stimulus  has  reached  a  definite  point, 
then  the  older  hypothesis  that  assumes  that  pleasure  passes  into 
pain  fails.  By  bearing  in  mind  the  analogies  in  skin  sensibility, 
it  would  appear  that  such  specific  receptors  are  probably  present, 
and  recent  studies  of  sensation  tend  to  show  that  they  are  pres- 
ent and  are  independent  of  others  of  a  lower  threshold  value. 
Should  this  principle  hold  true  for  the  sensory  systems  through- 
out, epicritic  and  protopathic,  our  conceptions  of  pain  and  its  re- 
lation to  pleasure  will  be  markedh'  altered  and  simplified;  we  then 
may  discard  much  of  the  metaphysical  speculations  regarding  the 
relations  of  pleasure  and  pain.  These,  however,  will  be  discussed 
more  fully  in  another  chapter. 


CHAPTER  II 

THE   NATURE  OF  PAIN 

Definition. — Various  definitions  of  pain  have  been  given  by- 
different  authors.  Meade  says  that  pain  is  an  indication  of  inter- 
ference with  the  power  of  nutrition  of  the  organism;  pleasure, 
of  the  elevated  power  of  nutrition  of  the  organism.  Oilman  thinks 
that  the  source  of  all  pleasure  is  the  renewal,  on  the  part  of  the 
nerves,  of  the  activity  that  has  already  become  familiar  to  them, 
while  pain  has  its  source  in  the  violation  of  nervous  habitude. 
Meynert  and  Oilman  think  that  the  effective  working  of  the 
psychic  functions  is  the  cause  of  pleasure,  while  any  obstacle  to 
these  functions  is  the  cause  of  pain.  Sidney  E.  Mezes  says  that 
pleasure  is  attention  without  difficulty  or  obstruction,  while  pain 
is  attention  with  difficulty.  This  applies  to  mental  pleasure  par- 
ticularly, as  close  attention  with  deep  thought  is  pleasant,  while 
obstruction  to  this  attention  and  thought,  due  to  internal  conflict, 
distress  of  mind,  or  other  causes,  is  painful  (Bianchi,  p.  346). 
Bianchi  further  says  that  whenever  there  is  internal  emotion,  or 
exteriorization,  in  response  to  the  needs  of  life,  there  is  pleasure; 
when  the  movement  is  hindered  or  obstructed,  there  is  pain. 

The  aspect  theory,  as  held  by  C.  D.  Strong  (473),  regards 
pain  as  the  highest  degree  of  displeasure,  and  holds  that  the  pain 
of  a  cut  or  of  a  burn  can  always  be  anal}'zed  into  a  tactile  or  tem- 
perature sensation,  on  the  one  hand,  and  a  feeling  of  displeasure 
on  the  other.  Kulpe  evidently  was  the  inspiration  for  this  idea, 
for  he  is  quoted  by  Strong  as  saying  that  "the  characteristic  fea- 
ture of  pain  is  not  the  sensational  quality,  which  is  never  absent, 
but  the  feeling  of  the  disagreeable,  of  which  pain  is  the  highest 
degree."  On  the  other  hand,  Lehmann  does  not  entirely  lose 
sight  of  the  sensational  element  of  pain  when  he  says:  "A  feel- 
ing, whether  of  pleasure  or  of  pain,  never  occurs  apart  from  a 
18' 


DEFINITION  19 

sensation,  however  weak,  and  in  every  case  where  such  an  isolated 
feeUng  is  supposed  to  have  been  observed,  the  sensational  element 
has  merely  been  overlooked." 

Meyers  (122,  p.  744)  says  that  pain  is  a  beneficent  reaction, 
through  the  nervous  system  of  altered  structure  or  disordered 
function,  against  threatening  forces.  Dunglison,  in  1857,  defined 
pain  as  "a  disagreeable  sensation  which  scarcely  admits  of  defi- 
nition "—truly  a  very  indefinite  definition.  Quain  (471),  not 
more  clear,  said  that  "  it  is  the  representation  in  consciousness  of  a 
change  produced  in  a  nerve  center  by  a  special  mode  of  excita- 
tion." Sudduth  says  that  "pain  is  a  mental  state,  an  element  of 
consciousness,  due  to  the  perception  of  an  injury  to  the  body  or 
to  the  feelings."  By  this  definition  it  is  seen  that  Sudduth  holds 
that  there  must  be  a  condition  of  mental  aptitude,  otherwise  it  is 
not  possible  to  decide  as  to  whether  or  not  an  injury  is  painful. 

Schopenhauer  turns  to  scholastic  philosophy  and  the  intro- 
spective method  of  deduction,  for  he  believes  that  "pains  are 
positive  and  pleasures  are  negative  experiences;  pleasures  are  due 
to  the  absence  of  pain,  and  the  intensity  of  one  is  often  in  propor- 
tion to  the  other  feeling  that  preceded  it."  Another  definition, 
of  the  same  character,  is  given  by  Spinoza,  who  says  that  "pleas- 
ure is  an  emotion  whereby  the  body's  power  of  activity  is  in- 
creased or  helped,  and  pain  is  an  emotion  whereby  the  body's  power 
of  activity  is  diminished  or  checked.  Therefore,  pleasure  in  itself 
is  good."     (Spinoza's  "Improvement  of  the  Understanding.") 

As  one  retreats  farther  into  the  past,  it  will  be  seen  that  the 
physical  properties  of  pain  were  not  perceived,  and  that  only 
a  metaphysical  interpretation  was  taken  into  consideration. 
The  early  Celts  and  Teutons  had  a  mythological  representation  of 
disease,  called  Hela,  a  ghastly  form  who  received  all  who  died 
of  disease  into  her  residence,  Niflheim.  In  this  were  the  Hall 
Elidnir  (pain),  her  bed,  Koer  (disease),  and  the  table,  Hungur 
(Allen,  510).  Cicero  described  pain  as  a  disagreeable  .move- 
ment in  the  body  (35);  Gambuus  called  it  a  disagreeable  sensa- 
tion which  the  mind  would  rather  not  experience;  while  Sauvage 
spoke  of  it  as  a  disagreeable  sensation  originating  from  any  lesion 


20  THE   NATURE   OF  PAIN 

of  nerve  fibers  (5).  Valentine  (507),  Wundt  (508)  set  forth  the 
idea  that  too  great  an  intensity  of  stimuH  may  cause  pain;  Erb 
held  that  every  increase  of  sensory  stimuli  is  capable  of  producing 
pain  as  soon  as  it  attains  a  certain  intensity;  Eulenburg  (509) 
states  that  it  is  a  gradual  increase  in  the  feeling  which  accom- 
panies every  sensory  process. 

From  the  preceding,  we  see  that  there  are  two  ideas  underly- 
ing the  various  definitions  for  pain;  the  one  physical  and  the  other 
metaphysical.  The  older  writers  dwelt  upon  its  psychological  as- 
pect, namely,  that  it  is  a  disagreeable  sensation,  while  the  modern 
thinkers  add  that  the  disagreeable  sensation  is  the  result  either 
of  lessened  nutritive  activity  in  the  cell  (receptive  or  perceptive), 
or  is  the  indicator  of  the  reaction  against  whatever  tends  toward 
the  destruction  of  the  organism. 

Universality  of  Pain. — As  an  evidence  of  the  universality  of 
pain,  we  find  words  expressing  it  in  all  languages;  and  as  evidence 
of  the  antiquity  of  its  existence,  we  find  that  the  word  expressing 
it  is  practically  the  same  in  all  languages  having  a  common  origin. 
In  the  English  language,  the  name  is  probably  derived  from  the 
Middle  English,  and  is  a  term  used  to  convey  the  idea  of  suffer- 
ing. This,  in  turn,  like  a  similar  expression  found  in  all  modern 
languages,  was  probably  derived  from  the  Latin  poena,  which 
means  a  punishment,  and  no  doubt  originated  in  the  Greek  word 
irolva,  also  meaning  a  punishment  or  penalty. 

Metaphysical  Consideration  of  Pain. — Is  pain  a  "sensation" 
or  a  "feeling"?  Meyer  believes  that  pain  consists  of  two  com- 
ponents, i.  e.,  sensation  and  feeling.  The  perception  element  is 
paramount,  when,  for  instance,  if  pressure  be  made  on  the  finger 
the  sensation  of  touch  would  be  experienced,  then  pressure,  and 
then  pain  would  be  experienced.  The  latter  is  a  feeling  qualify- 
ing or  superimposed  upon  touch.  Therefore,  he  asks,  is  pain  a 
true  sensation  or  is  it  only  a  perception  and  interpretation  of  a 
sensation  to  which  the  conscience  has,  from  past  experience, 
learned  to  give  the  name  pain?  For  instance,  is  it  possible  for  us 
to  know  what  pain  is  unless  we  have  been  informed  at  one  certain 
time  of  the  sensation  which  we  were  then  at  that   time  experi- 


METAPHYSICAL  CONSIDERATION   OF  PAIN  21 

encing.  If  we  adopt  such  an  interpretation  we  must  regard  pain 
as  a  "feeling."  We  have  been  considering  pain  as  a  sensation. 
This,  according  to  Marshall  ("Pleasure  and  Pain,"  p.  25),  is  un- 
tenable, for  the  following  reasons: 

A  sensation  must  have  a  receptive,  a  conducting,  and  a  per- 
ceptive organ  and 

(1)  Xo  center  for  pain  has  ever  been  defined  or  located.^ 

(2)  Xo  special  means  for  pain  production  are  present,  as  in 
the  case  with  other  sensations. 

(3)  Pain  is  aroused  by  the  most  varied  stimuli,  while  sensa- 
tions are  aroused  by  well-defined  and  limited  stimuli,  which  must 
be  exerted  upon  a  Special  sensory-perceptive  apparatus. 

(4)  Sensations  are  themselves  both  painful  and  pleasant; 
therefore,  pain  and  pleasure  are  but  attributes  of  sensation;  and 
cannot  exist  by  themselves  as  separate  sensations.  For  instance, 
heat,  cold,  taste,  smell,  hearing,  and  sight  may  all  be  painfully, 
as  well  as  pleasurably,  perceived. 

(5)  Pain  may  exist  in  the  intellect  without  any  peripheral 
cause,  but  in  this  case  it  generally  acts  as  a  qualifying  factor  in 
emotion,  which  is  a  mental  state.  It  is  extremely  difficult  to  say 
whether  an  abstract  idea  can  or  cannot  be  painful.  Perhaps  the 
most  we  can  say  is  that  it  is  either  agreeable  or  disagreeable. 

(6)  An  argument  sometimes  advanced  against  pain  being  a 
sensation  is  that  we  can  draw  up  in  imagination  a  representation 
of  sensation  without  its  actual  presence;  but  we  cannot,  by  any 
stretch  of  imagination,  conjure  a  picture  of  a  pain,  but  must  al- 
ways associate  it  with  some  sensation,  such  as  touch,  heat,  cold,  etc. 

Xewer  research  has  shown  that  Marshall's  position  is  abso- 
lutely untenable,  but  we  shall  for  a  moment  discuss  its  merits  and 
demerits,  with  the  hope  of  adding  light  to  the  whole  subject.  With 
regard  to  Marshall's  first  proposition,  that  no  center  for  pain  has 
ever  been  defined  or  located,  it  may  be  said  that  while,  as  a  rule, 
physiologists  and  psychologists  do  not  limit  pain  perception  to  a 
particular  region  of  the  brain,  they  hold  a  rather  unanimous  belief 

•  At  the  present  time,  however,  most  physiologists  hold  that  the  pain  center 
is  located  in  the  optic  thalamus. 


22  THE   NATURE   OF  PAiN 

that  the  sensations,  of  which  pain  constitutes  a  part,  have  their 
centers  in  the  postcentral  gyri.  Calkins  speaks  more  definitely. 
He  holds  that  the  centers  for  pleasure  and  pain  are  in  the  frontal 
lobes,  and  that  it  depends  upon  the  state  of  nutrition  of  these 
cells  whether  the  excitation  which  comes  from  the  motor  areas  of 
the  Rolandic  fissure  produces  pleasure  or  pain.  If  the  cells  are  in 
a  building-up  process,  that  is,  in  the  stage  of  anabolism,  the  result 
is  pleasure;  if  they  are  fatigued,  the  result  is  pain.  If  the  state 
of  nutrition  exactly  corresponds  to  the  state  of  need,  the  result 
will  be  neither  pleasant  nor  painful,  but  will  be  one  of  indiffer- 
ence. This  is  a  purely  speculative  hypothesis.  What  produces 
the  nutritive  derangement  in  the  frontal  lobes?  It  is  a  fact  that 
a  patient  who  is  fatigued  will  feel  painful  stimuli  more  acutely 
than  one  who  is  not  in  such  a  state  of  fatigue;  but  it  is  also  true 
that  fatigue  is  not  necessary  to  the  perception  of  pain,  since  even 
those  who  are  in  the  best  of  health  may  suffer  from  it. 

More  recently  it  has  been  held  that  the  pain  perceptive  cen- 
ters lie  in  the  cortex  of  the  postcentral  convolutions,  but  Thomas 
and  Gushing  (512)  found,  during  an  operation,  that  the  post- 
central convolutions  could  be  manipulated  without  pain,  the  pa- 
tient at  this  time  being  perfectly  sensible  and  alert  to  all  sensory 
phenomena.  The  operation  consisted  of  incision  of  the  cerebral 
cortex  and  removal  of  a  tumor,  all  without  pain.  During  the 
operation,  the  patient  had  not  the  "least  sensation  of  any  descrip- 
tion, though  the  operative  technic  required  the  cutting  across  and 
the  breaking  up  of  many  fibers,  as  well  as  the  irritation  of  the 
gray  matter."  It  is  interesting  to  observe  that  these  areas  cred- 
ited by  many  with  pain  production  were,  when  irritated,  entirely 
insensitive.  This,  however,  may  net  entirely  negate  their  pres- 
ence because  painful  stimuli  are  effective  only  in  the  receptor 
end  of  the  neuron  or  in  the  course  of  the  neuron,  and  it  is  likely 
that  the  center  of  perception,  since  it  possesses  no  adequate  ap- 
paratus to  receive  a  pain  stimulus,  would  be  unable  to  perceive  it. 
Centrally  projected  pains,  as  from  thalamic  lesions,  are  of  an- 
other type.  Here  the  associative  memory  centers  lie  and  at  the 
s^me  time  it  is  the  region  where  the  third  neuron  of  the  sensory 


METAPHYSICAL  CONSIDERATION   OF  PAIN 


23 


nerves  arises — and  thence  passes  to  the  periphery.  However,  if 
centers  for  pain  perceptions  are  admitted,  there  must  be  more  than 
one;  and  at  least  two  must  be  separated:  (a)  centers  where  the 
sensations  are  received,  and  from  whence  they  are  projected  to 
the  perceptive  centers,  as  the  thalamus,  for  instance  {see  tha- 
lamic lesions),  and  (b)  centers  which  record  the  painful  impres- 
sions in  memory,  and  in  the  future,  either  upon  some  subjective 
or  peripheral  irritation,  project  them  into  the  perceptive  centers, 
where  they  give  rise,  in  consciousness,  to  the  sensation  called  pain. 
The  following  diagram  exemplifies  the  meaning  of  this: 

^         ^  SigHT 

HeftRirvg 

"Reception  Center 
Tpvste 


lVlElV\OKy 

Center 


Center 


Fig.  3. — Schematic  Illustration,  Showing  How  the  Various  Sensa- 
tions ARE  Transmitted  from  the  Periphery  to  the  Brain  Cortex 

AND  from  thence  TO  THE  TwO  BrAIN  CeNTERS. 
(I)  The  ideahon  center  wliere  the  different  perceptions  are  correlated  into  thoughts 
and  ideas  (objective  sensation),  and  (2)  the  mrinory  center,  where  the  separate 
perceptions  are  stored  until  again  they  are  called  into  consciousness.  A  block  at 
A  would  occlude  all  sensory  perception  of  stimuli  and  the  memory  storage  of  the 
same.  A  block  at  b  would  occlude  the  transmission  of  present  acting  sensory 
stimuli,  so  that  they  would  not  l)c  perceived  in  consciousness.  However,  the  ctn- 
ter  still  receives  impulses  from  the  memory  center,  which  it  may  evolve  into  con- 
sciousness where  they  are  perceived  as  acting  in  the  present  (subjective  sensation). 
If  the  path  to  the  memory  center  is  destroyed,  all  recollections  of  prior  sensations 
are  lost,  and  the  ideation  center,  owing  to  lack  of  comparison  with  previous  sensa- 
tions, would  be  unable  to  correctly  interpret  the  ones  it  then  receives  and  may 
interpret  cold  as  heat,  etc,  (paresthesia). 


24  THE   NATURE    OF   PAIN 

Memory  Centers  for  Pain. — It  is  further  evident  that  all  of 
the  energy  received  in  the  areas  for  painful  impressions  is  not 
transferred  to  the  areas  of  perception  of  pain,  but  that  some  of 
it  is  transmitted  to  the  memory  areas,  from  v;hence,  in  the  future, 
it  may  be  transferred  to  the  areas  of  mental  perception  of  pain, 
thus  giving  rise  to  pain  which  is  subjective  in  consciousness,  and 
therefore  called  subjective  pain. 

In  regard  to  Marshall's  second  point,  it  will  be  shown  later 
that  special  fibers  for  pain  conduction  do  exist  in  the  peripheral 
nerves,  cord,  and  brain  (cortex),  and  that  these  fibers  carry  im- 
pulses from  pain  receptors  existing  in  special  areas,  and  have  the 
single  function  of  carrying  pain  impulses  and  no  others.  Head 
has  done  more  than  any  other  observer  to  establish  the  fact  that 
the  different  sensations  have  separate  receptive  organs,  which  re- 
ceive stimuli  peculiar  to  them  and  to  no  others. 

Marshall's  third  objection  is  harder  to  meet,  in  the  present 
state  of  knowledge,  for  it  may  be  true  that  certain  irritations, 
exerted  to  excess  on  some  sense  organs,  may  produce  pain.  While 
as  yet  no  specific  pain  fibers  have  been  discovered  to  be  present 
in  the  retina  of  the  eye,^  it  is  not  improbable  that  such  fibers 
exist;  or,  should  they  not  exist,  that  the  reaction  which  excess  of 
stimulus  produces  in  the  receptive  optic  cells  in  the  brain  causes 
fatigue  of  those  cells  and  that  this  is  transmitted  to  the  fibers  of 
adjacent  cells,  in  which  a  reaction  interpreted  as  painful  is  pro- 
duced. That  such  a  hypothesis  is  not  entirely  without  basis,  may 
be  seen  from  the  assertion  that  ^'thcre  are  special  pain  nerves  run- 

Un  this  respect,  Foster  ("Physiology,"  5th  edn..  Part  IV,  pp.  281, 
282)  agrees  with  Goldseheider  (473,  "  Ueber  den  Schmerz,"  p.  8),  and  in 
speaking  of  the  pain  from  stimulation  of  the  retina  says:  "We  have  no  evi- 
dence that  simple  stimulation  of  the  retina,  however  excessive,  will  give  rise 
to  pain,  meaning,  by  pain,  tlie  kind  of  sensation  we  feel  when  the  skin  is  cut 
or  burnt.  We  have  no  evidence  that  an  auditory,  or  an  olfactory,  or  a 
gustatory  sensation  can,  through  mere  intensity,  become  converted  into  a  sen- 
sation of  pain.  We  may  assume  that  the  pain  which  we  feel  when  the  finger 
is  cut  is  a  wholly  different  thing  from  the  pain  which  is  given  to  the  most 
delicately  musical  ear  by  even  the  most  horrible  discord."  These  considera- 
tions suggest  to  Foster  that  cutaneous  pain  is  not  simply  an  exaggeration  of 
tactile  and  temperature  sensations,  but  a  separate  sensation  developed  in  a 
different  way. 


CAUSATIVE  FACTORS  IN  THE  PRODUCTION   OF   PAIN     25 

ning  parallel  to  and  in  the  same  trunk  with  the  sensory  nerves, 
having  a  special  sense  of  perception  in  the  brain,  and  operating 
only  under  the  influence  of  intense  irritation."  Matzinger's  (328, 
p.  138)  statement,  that  "it  is  unlikely,  and  contrary  to  natural 
laws,  that  there  should  be  an  elaborate  mechanism  of  highly  or- 
ganized tissue  which  is  destined  never  to  come  into  use  in  some 
individuals,  or  at  least  only  in  a  very  limited  way,"  will  have  to 
undergo  modification,  for  it  has  been  proven  that  there  are  such 
tissues  in  the  form  of  special  nerves  (pain,  etc.)  for  certain  types 
of  sensation  (Edinger,  Head,  Strumpell,  etc.). 

As  to  the  fourth  objection,  that  pain  must  be  an  attribute  of 
sensation  because  each  sensation  may  be  both  painful  and  pleas- 
ant, it  is  rather  difficult  to  formulate  a  proper  answer.  Were  it 
not  for  its  clear  separation,  jn  the  skin,  from  all  other 
sensations,  one  would  be  forced  almost  naturally  to  the  con- 
clusion that  pain  really  is  only  a  qualifying  factor  in  sensation. 
Yet  it  is  possible  that  the  pain  sense  which  one  finds  in  the 
periphery  is  a  highly  differentiated  touch-sense;  that  pain  is 
present  in  other  organs  from  a  too  great  stimulation  of  their 
sensory  end  organs;  and  in  their  centers  from  overactivity. 

The  fifth  and  sixth  arguments  are  not  supported,  in  view  of 
the  general  hypothesis  that  there  are  specific  pain  sensations. 

Causative  Factors  in  the  Production  of  Pain. — The  produc- 
tion of  pain  depends  upon  the  presence  of  a  projDer  stimulus  and 
the  integi'ity  of  the  receptive,  the  conveying,  and  the  interpreting 
apparatus.  The  stimuli  may  be  divided  into  those  due  to  me- 
chanical changes  in  pressure,  to  toxemia,  to  chemical  changes,  and 
to  electric  or  thermic  reactions.  The  stimuli  due  to  mechanical 
changes  are  exerted  either  upon  the  terminal  filaments  of  the 
nerve,  or  on  some  of  the  neurons  extending  from  the  brain  to  the 
periphery.  This  mechanical  irritation  may  be  due  to  pressure 
from  an  inflammatory  exudate  (see  Inflammatory  Pain),  to  pres- 
sure hy  new  groivtlis,  or  to  prolonged,  strong  contraction  of  a  hol- 
low organ  (Mackenzie).  Hemorrhage  in  the  body  tissues  will 
almost  invariably  cause  either  deep  pressure  pain,  or  epicritic  pain 


26  THE   NATURE    OF   PAIN 

(Head),  unless  the  rupture  is  an  areolar  tissue,  when,  owing  to  the 
looseness  of  the  tissues,  pain  is  not  j)resent  until  the  local  dis- 
tention becomes  excessive,  or  until  pressure  is  made  on  adjacent 
structures.  In  regions  where  the  tissues  are  denser  and  more  com- 
pact, pain  is  very  severe,  even  from  the  beginning  of  the  hemor- 
rhage, as  in  hemorrhagic  pancreatitis.  In  cavities,  also,  hemor- 
rhage is  often  provocative  of  the  most  intense  distress.  This  is 
particularly  true  of  the  peritoneal  cavity.  The  cause  of  this  ex- 
cessive pain  is  rather  hard  to  determine,  in  view  of  the  fact  that 
in  this  location  the  resistance  to  the  hemorrhage  is  almost  nega- 
tive. It  may  be  that  blood  possesses  some  substances  which  are 
particularly  irritating  to  the  peritoneum,  and  that  this  irritation 
is  transmitted  to  the  body  wall  as  pain.  Even  as  hemorrhage 
causes  pain,  so  also  in  some  cases  of  congestion,  it  eases  the  pain, 
as  in  swollen  turbinates,  premenstrual  congestion  of  the 
uterus,  etc. 

The  extent  of  the  surface  stimulated  is  important  in  the  pro- 
duction of  certain  kinds  of  pain.  If  the  area  of  stimulated  sur- 
face is  too  small,  no  pain  is  felt.  It  seems  that,  in  certain  areas, 
only  an  aggregate  of  stimuli  can  produce  pain  (Tigerstedt,  483, 
p.  467). 

The  stimulus  Avhich  causes  pain  may  not  be  of  any  greater 
magnitude  than  that  which  is  daily  experienced  by  the  organism; 
yet,  from  frequent  repetition,  a  condition  is  reached  in  which, 
before  recovery  from  one  stimulus,  the  cell  receives  another,  and 
so  on.  Each  stimulus  leaves  a  little  of  its  irritative  quality, 
until  the  tension  from  the  accumulation  of  these  irritative 
remnants  becomes  too  great,  and  release  of  nervous  energy 
takes  place  in  the  cell,  the  pain  threshold  is  reached  and  the 
sensation  of  pain  results.  After  once  having  overcome 
the  threshold,  secondary  discharges  take  place  on  a  slighter  provo- 
cation. 

Sudden  alterations  of  blood  pressure  create  pain,  as  is  seen 
when  a  tourniquet,  which  has  been  on  a  limb  for  several  hours> 
is  removed. 

Toxemia  is  a  cause  of  pain,  particularly  in  severe  anemia  of 


CAUSATIVE  FACTORS  IN  THE  PRODUCTION   OF   PAIN      27 

a  part,  such  as  is  found  in  emboli  of  the  arteries.^  James  re- 
ported a  case  of  complete  obstruction  in  circulation  of  the  aorta, 
in  which,  after  the  ligation,  the  patient  had  the  most  severe  pain 
(D.  W.  Mitchell,  263,  p.  52).  The  causes  of  this,  ''Brown- 
Sequard  thought  to  be  an  accumulation  of  CO2  in  the  tissues. 
Vulpian  regarded  it  as  being  due  to  the  lack  of  oxygen,  while  W. 
Mitchell  thought  that  it  might  be  due  to  sudden  annihilation  of 
nutrition,  osmosis  and  conditions  of  pressure." 

Pain  may  also  be  due  to  the  accumulation  of  toxic  products 


I  complete  v     , 

.imilaTior,  \T 

omplele  /^ 

strCclion  ' 


Melabolisrt 


Abnormal    ""^        Comolele       /  X, --Non-Complete 

Destruction    '  \     Elimination 

.   ,  \                                             increased  Jensoru  , 

Asiimilalion  V  ..  A    ..       ..        _.      .          /     i„.,,i:.i....        ^^ 


Metaboi;5m_/     Compfete"  XtoxIc  Non  compUlA  Act  on  the  ^Produce  /     l^'^'tabiilt^ 

Abnormal  ~\   Non  complete  /Producti        Elimination  /N"^^^«liy^„  \  Increased  Motor   ^ 

\  Destrucfion   ^  /  iS^mejor Jn'^other  Irritability, ^ 

/  Non-complete  V 
Metabolism      /    Assimilation  \ Toxic P 
Abnormal  ~A.    Non  complete  / 

^    Destruction    -^ 


formed  or  on  ottier 
■  Non-complete  V  /       nerve  cells  throuqli 

Assimilation  \TollltProdut^^  A       the  means  of  the 

culalion 


This  maij  account  for  certain  of  tlie  pains  whicti  we  find  in  tiijsterical  conditions 

Fig.  4. — Diagram  showing  How  Changes  in  the  Cell  Metabolism  May 
Produce  Changes  in  the  Irritability  of  the  Cell  and  a  Depar- 
ture IN  ITS  Reaction  to  External  Stimuli,  Either  Making  it 
More  or  Less  Sensitive  to  Peripheral  Irritation. 

in  a  part,  as  exemplified  in  the  fatigue  pains  of  muscle,  wherein 
the  products  are  the  result  of  metabolic  waste;  or  else  the  toxin 
may  be  derived  from  exogenous  sources,  as  from  the  alimentary 
tract  or  from  an  outside  toxic  agent,  alcohol,  etc.  It  may  also  be 
the  result  of  toxins  from  bacterial  organisms.  The  toxin  acts 
upon  the  receptor  cells,  or  on  the  sensory  nerve  substance  to 
which  the  irritant  may  be  transferred. 

As  to  cliemical  causative  factors,  there  may  be  many,  princi- 
pally in  burns,  severe  ischemias,  etc.  From  the  nature  of  the 
condition,  toxemias  might  also  be  classed  among  chemical  agents, 
inasmuch  as  in  toxemia  the  poison  or  irritant  is  of  a  chemical 
nature. 

M^ery  severe  pain  is  felt  in  infarct  kidney  (Halperin).  Pain  is  also 
extremely  severe  in  arteriosclerotic  thrombosis  (Buerger  and  Geis).  Intense 
pain  is  also  felt  in  arteriosclerotic  thrombosis  of  the  lower  limb,  a  disease 
which  is  especially  prevalent  among  the  Eussian  Jews.  The  pain  is  so  agon- 
izing and  constant  that  the  poor  sufferers  will  consent  even  to  the  extreme 
remedial  measure  of  amputation  rather  than  bear  longer  suffering. 


28  THE  NATURE   OF   PAIN 

Decreased  allcalinity  of  the  hlood,  as  suggested  by  Sir  Lauder 
Brunton,^  may  also  produce  pain.  This  may  explain  the  cause 
of  the  generalized  aching  pain  that  is  present  in  infectious 
diseases. 

Pliotocliemical  changes  in  the  rods  and  cones  of  the  retina  of 
the  eye  are  produced  by  light.  When  the  light  is  too  severe,  these 
changes  are  excessive,  and  the  stimulation  of  the  optic  nerve 
is  stopped  or  modified,  so  that  vision  is  obscured  and  j)ain  results 
(Matzinger,  328,  p.  139). 

In  some  cases  trophic  changes  in  the  skin  may  also  produce 
pain.  This  may  be  peripheral,  due  to  irritation  of  the  sensory 
receptors  (protopathic),  or  central,  due  to  changes  in  the  sensory 
cell  distribution  in  the  cord. 

Electrical  reactions  cause  pain,  as  may  be  proven  by  the  use 
of  the  painful,  interrupted  electrical  current  (Head,  519).  This 
is  one  way  of  testing  sensitiveness  to  pain  (see  Intensity  of  Pain), 

Heat  and  cold  are  frequent  causes  of  pain  production,  the 
reason  evidently  being  some  chemical  change  in  the  region  of  the 
sensory  receptors.  This,  however,  will  be  more  fully  considered 
in  the  section  devoted  to  the  relation  of  pain  to  temperature. 
Freezing  of  a  nerve  will  cause  such  an  irritability  of  the  nerve, 
below  the  point  frozen,  that  the  least  pressure  upon  it  causes  pain 
in  its  distributive  area  (Weir  Mitchell,  2G3,  p.  18). 

Apparatus  for  Receiving  and  Conducting  Pain. — The  various 
forms  of  receptive  apparatus  are  not,  as  yet,  well  defined.  Special 
terminal  filaments  are  present  for  certain  forms  of  stimuli,  but 
their  distribution  is  little  known.  From  the  universal  presence  of 
pain,  it  Avould  seem  that  the  sense-receptive  organs  for  pain  are 

^  Sir  Lauder  Brunton  (516)  states  that  he  became  infected  with  the 
staphylococcus  pyogenes  aureus,  and  that  numerous  boils  developed  which  had 
a  stinging,  burning  pain,  generally  worse  about  three  or  four  hours  after 
eating — a  time  when  digestion  would  be  most  active,  the  absorption  of  the 
acid-formed  contents  of  the  stomach  greatest,  and  the  alkalinity  of  the  blood, 
from  their  absorption,  least.  From  this  he  concluded  that  the  pain  was  due 
to  a  decreased  alkalinity;  and,  proceeding  on  this  assumption,  he  took  fairly 
large  doses  of  alkalies,  with  a  resulting  diminution  of  pain.  He  then  tried 
the  effect  of  the  biearbonates,  applied  directly  to  the  boils,  with  a  consequent 
diminution  of  pain.  In  toothache,  also,  the  application  of  bicarbonate  of  soda 
to  the  cavity  of  the  tooth  has  a  beneficial  effect. 


APPARATUS  FOR  RECEIVING  AND   CONDUCTING  PAIN     29 

widely  dijffused.  These  receptors  are  capable  of  receiving  pain 
stimuli  of  various  kinds,  toucli,  deep  pressure,  heat,  cold.  Their 
action  may  be  abrogated  by  excessive  cold,  cocain,  vibration,  elec- 
tricity, etc.  These  terminal  filaments  in  the  skin  have  been 
called  noci-ceptors  (nocuous  ceptors)  by  Sherrington  (522).  He 
classifies  as  receptors  all  organs  in  the  skin  and  mucous  mem- 
branes which  have  developed  by  a  long  series  of  evolutionary 
changes,  and  which  have  the  ability  to  distinguish  stimuli  arising 
from  different  sources,  such  as  temperature,  pressure,  or  touch. 
Those  portions  of  the  body  most  subject  to  injury  should,  there- 
fore, have  a  more  numerous  supply  of  noci-ceptors  than  those 
portions  which  are  not  so  exposed.  If  this  is  true,  we  should 
find  the  fingers,  which  are  exposed  to  injury,  better  supplied  with 
these  ceptors  than  the  brain,  which,  because  of  its  inclosure  in  the 
skull,  is  prevented  from  injury.  Such  is  the  case;  for  in  the 
brain,  the  cortex  is  found  to  be  relatively  insensitive  to  many 
stimuli  which  ordinarily  cause  pain  sensations  (Crile  and  Sher- 
rington). 

The  pain-conducting  a-pyaratus  consists  of  the  nerve  fibers 
leading  from  the  periphery  to  the  sense-perceptive  centers.  Any 
irritation  to  the  axis  cylinders  of  the  sensory  nerves  in  this  path- 
way will  be  transmitted  to  the  periphery  and  be  felt  as  pain.  Irri- 
tation may  be  in  the  form  of  inflammation  of  the  nerve  (neuritis), 
of  the  ganglion  (herpes),  of  the  post  roots  (tabes)  within  the  cord 
(transverse  myelitis),  or  in  the  thalamus.  Various  agents  may 
act  upon  the  axis  cylinder  processes  (nerves),,  such  as  tetanus 
toxins,  arsenic,  alcohol,  etc.  The  headaches  of  toxic  origin,  fa- 
miliar to  all,  are  usually  due  to  stimuli,  acting  upon  the  dural 
distribution  of  the  trigeminus. 

Pressure  on  the  conducting  fibers  causes,  as  a  rule,  a  severe 
pain  reaction.  Yet,  it  is  possible  for  pressure,  when  equal  and 
constant,  to  be  very  severe  without  producing  any  pain  reaction. 
It  seems  most  potent  for  pain  production  when  it  varies  in  in- 
tensity; the  more  variable  the  pressure  the  greater  the  severity 
of  the  pain.  Such  a  pressure  we  see  exerted  by  new  growths,  as 
tumors  or  cysts,  or  by  inflammatory  changes,  as  in  meningitis. 


30  THE   NATURE    OF   PAIN 

The  sense-perceptive  centers  in  the  hrain  may,  from  oft- 
repeated  stimulation,  become  hypersensitive.  It  is  often  the  case 
that,  after  the  original  cause  has  ceased,  the  hypersensibility  re- 
mains, so  that  stimuli  of  ordinary  intensity,  when  they  reach  these 
centers,  may  be  interpreted  as  painful.  Whether  this  is  due 
to  a  hyperactivity  of  cortical  cells,  or  to  a  lowering  of  the  thresh- 
old values  in  the  receptors,  has  not  as  yet  been  definitely  estab- 
lished. The  so-called  occupation  neurosis,  in  which  pain  is  pres- 
ent when  the  patient  attempts  to  perform  some  accustomed  task  of 
manual  dexterity,  may  serve  as  an  example  of  this.  Here  the 
pain,  as  well  as  the  spasm  which  accompanies  it,  may  be  said  to 
represent  a  rebellion  on  the  part  of  the  overused  cortical  centers. 
This  rebellion  does  not  seem  to  be  so  much  upon  the  part  of  iso- 
lated centers  as  due  to  fatigue  in  the  association  of  certain  stimuli, 
which  are  carried  to  the  affected  area  from  other  centers,  and  which 
have  the  power  of  producing  certain  coordinate  actions.  The  same 
centers  may  be  called  into  play  to  make  other  movements  of  the 
same  muscles  without  producing  pain.  Thus,  a  person  who  is  un- 
able to  write  without  pain  may  be  able  to  sew  without  any  trouble 
(Walton,  517,  p.  261).  It  should  not  be  overlooked,  however, 
that  such  acts  are  only  apparently  similar.  In  reality  they  are 
quite  diverse. 

We  have  spoken  of  the  lowering  of  the  threshold  to  pain.  In 
neurasthenia  it  would  appear  that,  for  reasons  as  yet  unknown, 
such  a  reduction  takes  place  so  that  the  body  is  more  capable  of 
reacting  to  stimuli  (including  pain)  than  when  it  is  in  a  normal 
state. 

Shock,  anxiety,  apprehension,  have  an  effect  in  lowering  the 
pain  thresholds  for  various  stimuli.  Just  what  the  molecular 
factors  may  be  underlying  this  change  no  one  knows.  Clouston's 
phrase,  "disturbance  of  molecular  equilibrium,"  is  as  good  as  any 
other,  whatever  it  may  mean. 

Pain  and  Mental  ^iaXe^.—E motioiis,  like  anger  and  fear, 
sometimes  give  rise  to  severe  nervous  attacks  which  are  typified 
by  headaches ;  and  in  this  relation  it  is  an  odd  coincidence  that 
only  the  unpleasant  emotions  give  rise  to  disagreeable  sensations. 


RELATION    OF    PAIN    TO    OTHER    SENSATIONS  31 

for  surely  no  one  has  ever  heard  of  a  pain  (headache)  being  pro- 
duced bj  joy  or  happiness.  Hypnosis  may  also  have  the  power  of 
bringing  into  the  patient's  consciousness  an  intense  perception  of 
pain.  Some  blindfolded  persons  will  experience  what  they  think 
to  be  pain,  if,  prior  to  running  a  cold  instrument  across  the  skin, 
they  are  told  they  were  going  to  be  cut.  In  the  dream  state,  also, 
vivid  sensations  of  pain  may  occur.  One  of  my  patients,  a  non- 
pregnant woman,  has  been  aroused  frequently  by  apparent  labor 
pains,  of  which  she  had  not  the  slightest  perception  upon  awak- 
ing. The  modus  operandi  of  this  perception  was  described  when, 
in  speaking  of  consciousness,  the  method  of  transference  of  im- 
pulses from  the  receptive  center  to  the  perceptive  center  was  il- 
lustrated. There  has  been  some  controversy  as  to  whether  it  is 
possible  to  imagine  pain.  The  answer  seems  to  be  simple;  for 
how  else  would  it  be  possible  for  the  hysteric  to  draw  from  mem- 
ory's store,  and  present  to  vivid  view,  sensations  which  are  as 
realistic  as  though  they  were  actually  taking  place  ?  And  is  not 
imagination,  of  which  the  hysteric  unconsciously  makes  abundant 
use,  but  the  power  of  transferring  sensation  from  the  warehouse 
of  past  experiences  to  the  mart  of  present  change  ? 

Relation  of  Pain  to  Other  Sensations.  ^ — AVe  now  approach  the 
most  difficult  part  of  our  subject,  namely  the  consideration  of 
pain  in  its  relationship  to  other  sensations.  Pain  is  so  inextricably 
mixed  up  with  other  sensations  that  at  first  it  would  seem  almost 
impossible  to  unravel  the  skein.  Yet,  the  riddle  is  not  so  difficult 
to  solve  if  we  only  recognize  one  factor,  and  always  consider  it  in 
our  study  of  this  subject.  This  factor  is  evolution.  If  we  reflect 
that  our  nervous  system  is  the  development  of  nameless  thousands 
of  ages ;  that  from  a  most  simple  form  it  has  developed  to  a  most 
complex  system ;  and  that  during  this  development  its  structures 
and  functions  have  constantly  been  modified  by  and  adjusted  to 
the  changes  in  environment,  it  is  easy  to  imderstand  how,  by  these 
constant  changes  and  innumerable  modifications,  it  has  reached  its 
present  complex  and  intricate  form.  The  nervous  system  at  first 
(in  our  progenitors)  was  very  crude,  being  little  more  than  that 
which  was  essential  for  the  carrying  on  of  the  two  great  functions 


32  THE   NATURE    OF   PAIN 

of  the  organism,  nanielv,  growth  and  reproduction.  As  the  or- 
ganism developed,  it  became  more  and  more  susceptible  to  external 
influences,  and  more  and  more  cognizant  of  its  environment  and 
the  physical  state  of  its  being.  At  the  same  time,  the  means  of 
defense  vrere  improving,  so  that  the  organism  was  better  able  to 
protect  itself  from  injury  and  the  external  dangers  of  which  it 
was  just  becoming  aware.  Probably  it  was  at  this  time  that  the 
various  external  senses  were  called  into  activity.  An  analogue  of 
this  is  seen  in  the  human  embr3'o,  in  which  it  is  held  (Mackenzie, 
69)  that  the  cerebrospinal  system  is  a  later  development  than  the 
sympathetic,  the  sympathetic  being  concerned  with  the  essential' 
processes  of  life,  while  the  cerebrospinal  is  concerned  only  in 
communicating  to  consciousness  the  relationship  to  surrounding 
objects,  the  relationship  of  different  portions  of  the  body  to  each 
other,  and  the  intensity  and  variety  of  stimuli  which  are  received 
from  different  sources.  In  other  words,  cognition  is  dependent 
upon  this  exterior  system.  So,  it  is  held  that  the  development  of 
the  cerebrospinal  system  is  for  the  purpose  of  defense  against 
injury,  and  that  the  principal  means  of  communicating  the  exist- 
ence of  such  an  injury  to  consciousness  is  by  a  series  of  disagree- 
able stimulations  which,  by  long  association,  have  been  grouped 
into  various  groups  and  are  called  pain. 

Yet,  pain  to  touch  is  not  the  only  sensation  which,  because  of 
ancestral  necessities,  has  been  developed  from  the  primal  sensi- 
bilities of  a  simple  organization.  In  the  same  class  are  tempera- 
ture, light  touch,  and  deep  sensibility.  Light  touch,  as  it  was  prob- 
ably the  last  to  develop,  is  the  most  vulnerable ;  so  that,  in  lesions 
of  the  peripheral  nerves  it  generally  is  found  to  be  one  of  the  first 
sensations  to  disappear.  Touch  and  pain  have  been  regarded  by 
some  as  variations  of  the  same  sensation.  From  the  following 
facts,  however,  these  two  sensations  cannot  be  considered  the  same : 

(1)  The  distribution  areas  of  touch  and  pain  are  not  identi- 
cal. Were  they  but  modifications  of  the  same  sensation,  their 
localizations  would  be  exactly  similar,  and  both  would  be  present 
at  the  same  time.  The  exact  opposite  of  this  was  present  in  a 
case  reported  by  Head  and  Thompson  (206,  p.  553),  where,  in  a 


RELATION   OF   PAIN    TO    OTHER    SENSATIONS  33 

lesion  of  the  spinal  cord,  an  area  on  the  limb  was  insensitive  to 
pain,  while  it  was  sensitive  to  light  touch  and  pressure.^ 

(2)  Another  illustration  in  point  is  given  bj  Biernacki 
(Witmer,  527),  who  states  that  pain  and  temperature  sense  can  be 
made  to  disappear  bv  pressure  on  the  ulnar  nerve,  while  the  other 
sensations,  as  touch,  localization,  and  muscular  sense,  remain. 
This  would  argue  either  for  special  nerves  of  pain,  or  else  for  the 
reduction  in  the  conductivity  of  individual  fibers ;  so  that  if  pain, 
in  the  case  of  touch,  is  due  to  increased  molecular  vibration,  the 
fibers  would  not  be  able  to  carry  the  stimulus.  Yet,  such  a  suppo- 
sition is  hardly  tenable,  from  the  fact  that  disease  of  the  cord, 
and  of  a  certain  area  of  it,  will  produce  a  loss  of  pain  conduction, 
but  not  of  light  touch ;  and,  vice  versa,  lesions  in  the  cord  may 
produce  a  disturbance  of  light  touch  perception  and  not  of  pain 
perception. 

In  a  case  reported  by  Gowers  a  unilateral  hemorrhage  into  the 
lateral  columns  and  gray  substance  of  the  upper  cervical  cord  pro- 
duced analgesia  and  thermoanesthesia.  In  this  case  there  was  a 
complete  loss  of  pain  on  the  opposite  side  of  the  body,  without 
disturbance  of  light  touch. 

From  the  above  it  would  seem  that  the  pain  and  temperature 
senses  are  more  closely  related  than  are  pain  and  touch.  In 
other  conditions  the  senses  of  touch  and  pain  appear  intimately 
related,  as  is  shown,  when  by  gradually  increasing  the  pres- 
sure on  a  part,  the  sensation  produced  changes  from  that  of  touch 
to  actual  pain,  Witmer  found  that  a  maximal  pressure  of 
1.0  gm.  or  2.0  gm.  will  give  the  sensation  of  touch  gTeater  in- 
tensity. The  same  stimulus,  ranging  from  20,0  gm.  to  15,0  kgm., 
produces  a  sensation  of  pressure,  while  at  times  a  pressure  of  5.0 
kgm.  to  15.0  kg-m,  will  give  rise  both  to  pressure  and  pain  sensa- 
tions. A  maximal  stimulus  above  15.0  kgm.  gives  rise  to  pain 
only.     This  Head  has  shown  is  due  to  specific  receptors  of  deep 

'  This  is  frequently  found  in  dissociation  paralysis,  which  is  conspicuously 
present  in  syringomyelia.  It  is  also  found,  less  marked,  but  much  more  fre- 
quently than  is  usually  assumed,  in  neurotic  processes,  in  tabes  and  in 
paralysis,  as  well  as  in  alcoholic  and  hysterical  persons.  (Osier's  "Modern 
Clinical  Medicine,"  "Diseases  of  the  Nervous  System,"  p.  194). 


34  THE  NATURE   OF   PAIN 

sensibility  whose  threshold  values  are   approximately  stated  hy 
Witmer. 

In  tabetics,  also,  it  is  very  common  for  some  dissociation  be- 
tween pain  and  touch  to  be  present,  as  frequently  the  patient  will 
feel  the  touch  of  a  pin  point  much  sooner  (one  or  two  seconds) 
than  the  pain  caused  by  its  penetration  into  the  skin.  The  term 
delayed  pain  sensation  is  given  to  this  state. 

A  dissociation  between  pain  and  touch  sensations  may  also  be 
present  under  the  action  of  cocain,  chloroform,  in  tabes  dorsalis, 
hysteria,  hypnotism,  etc.  During  operations,  when  anesthesia  is 
not  complete,  it  is  rather  common  for  the  patient  to  complain  that 
he  feels  the  touch  of  the  knife,  but  no  pain.  Should  pain  be  present 
and  touch  be  absent,  the  patient  will  be  unable  to  localize  the  pain ; 
and,  inversely,  it  is  found  that  the  more  acute  the  tactile  sense  of 
a  part  is,  the  more  accurate  is  the  localization  of  pain  in  that 
part  (Hall,  p.  4-i2). 

Of  the  sensations,  pain  and  temperature  seem  to  be  the  one'' 
most  closely  connected — at  least,  this  holds  true  in  regard  to 
the  cord,  for  lesions  here  more  frequently  produce  a  dissociation 
between  the  other  sensations  than  between  pain  and  proto- 
pathic  temperature.  That  they  represent  degrees  of  the  same 
sensation  cannot  be  held,  because,  in  the  first  place,  the  tempera- 
ture sensation  may  remain  when  all  the  others  are  absent  (Head 
and  Rivers,  Ref.  86).  In  such  cases,  the  patient  does  not  respond 
to  painful  tactile  stimuli,  but  to  painful  heat  or  cold  stimuli. 
This  w^ould  apparently  show  a  difference  cither  in  the  origin  of  or 
in  the  conduction  of  these  two  sets  of  stimuli.  Yet,  heat  pain  can  be 
produced  by  a  temperature  of  3G.3°  C.  to  52.6°  C,  and  cold 
pain  by  a  temperature  of  +  2.8°  C.  to  —  11.4°  C.  (Dana, 
529),  when  the  tactile  sensibility  and  the  cutaneous  pain  sensa- 
tion are  lost.-^     This  differentiation  of  sensation  can  occur  only 

^According  to  Weber,  "the  pain  produced  by  heat  and  cold  is  very  dif- 
ferent from  the  sensation  of  heat  or  that  of  cold.  If  the  pain  is  not  extreme 
we  feel  at  the  same  time  the  heat  or  cold  which  causes  it,  and  can  then  dis- 
tinguish pain  due  to  heat  from  pain  due  to  cold.  But  if  it  is  extreme,  the 
sensation  is  the  same,  whether  caused  by  heat  or  cold"  (Strong,  473),  The 
pain  sensation  is  located  deeper  in  the  skin  than  the  terminal  filaments  which 
transmit  cold,  because,  "on  contact  of  a  cylinder,  slightly  heated,  with  the 


CONVEYING    CHANNELS    FOR    SENSATIONS  35 

wlien  the  superficial  nerve  is  diseased,  and  deep  sensibility 
I'cmains ;  for  the  part  of  the  nerve  conveying  deep  sensibility  runs 
with  the  muscular  branch  of  the  superficial  nerves,  and  so  may 
•.•3cape  injury  in  case  of  destruction  of  the  cutaneous  sensory 
1  :-anch.  The  sensibility  to  temperature  changes  is  itot  equally 
distributed,  it  being  greater  in  some  places  than  in  others.  That 
heat  and  cold  sensations  have  separate  receptors  can  be  deduced 
from  the  fact  that  one  may  be  present  in  the  absence  of  the  other. 
Ixivers  and  Head  (86)  report  a  case  where  the  sensation  to  cold 
was  independent  of  any  other  sensation.  It  has  been  known  for 
some  time  that  heat  and  cold  sensations  have  special  areas  on  the 
skin  where  they  alone,  of  all  the  sensations,  are  present  (Gold- 
scheider).  Thus  it  will  be  seen  that,  in  the  course  of  development, 
certain  nerve  elements,  becoming  more  highly  specialized,  have 
arrogated  to  themselves  special  functions,  one  of  which  is  tlie 
l^ower  of  being  stimulated  by  hot  and  cold  objects.  These  recep- 
tors, devised  for  temperature,  are  insensitive  to  electrical  and 
mechanical  stimuli  (Kivers  and  Head,  86,  p.  385).  It  has  also 
been  found  that  stimulation  of  temperature  points  or  spots  by  a 
needle  will  not  produce  pain  (Tigerstedt,  483).  Excessive  stimu- 
lation by  heat  or  cold  may  produce  only  the  sensation  of  pain. 
While  it  is  probable  that  the  correlated  sensations  (heat  or  cold) 
are  present,  they  are  not  felt  because  of  the  overwhelming  of  the 
consciousness  by  the  intensity  of  the  pain  sensation.  Hyperalgesia 
to  temperature  may  be  present  without  hyperalgesia  to  touch 
(Stern,  "Archiv  fiir  Psychiatric,"  1886);  and  it  has  also  been  noted 
that  hyperalgesia  for  heat  may  not  be  as  marked  as  it  is  for  cold. 
Conveying  Channels  for  Sensations. — It  is  apparent  that  while 

skin,   on   which  a  blister  had  been  applied  and   the  epidermis  removed,   a  painful 
stimulus  without  a  trace  of  heat  sensation  was  felt"   (Mettler,  505). 

A  case  in  point  is  reported  by  Barker,  in  which,  because  of  pressure  of  a 
cervical  rib,  certain  conditions  occurred  in  the  area  of  distribution  of  the 
nervi  cutanei  brachii  et  antebrachii  mediales  of  the  left  arm.  He  found  that 
in  some  areas  careful  testing  showed  that  pricks  with  a  fine  needle  gave  only 
pain,  without  calling  forth  previous  touch  or  pressure  symptoms.  Ice  at  first 
gave  no  sensation,  then  pain.  Heat  gave  rise  only  to  heat  pain,  without  pre- 
vious heat  sen.sation.  A  stimulus  of  47°  C.  (116.6°  F.)  and  upward  quickly 
caused  pain,  but  no  sensation  of  warmth.  Barker  claims  that  the  pain  was  due 
to  stimulation  of  pain  organs.     (Witmer,  527.) 


36  THE  NATURE   OF  PAIN 

the  sensations  of  touch,  temperature,  pain,  and  deep  pressure  pain 
are  closely  related,  they  are  separate  entities,  and  that  each  is 
carried  by  its  own  specially  differentiated  and  functionating 
nerves.^  We  have  already  referred  to  these,  but  will  discuss 
them  again  more  at  length. 

*  There  has  always  been  considerable  discussion  among  physiologists  as 
to  the  presence  of  pain  nerves  and  pain  tracts.  Advocating  the  existence  of 
pain  nerves  are  Strong  (533),  Krehl  (534),  Von  Frey,  Piersol  (537),  Nichols, 
Bianehi  ("Psychiatry,"  p.  358),  Funke,  Head,  Goldscheider,  etc.  Opposing 
the  idea  are  Hall,  Marshall,  Mantegazza  (536),  Dana,  Brown-Sequard,  Mun- 
sterberg,  James,  Ziehen  and  Weir  Mitchell   (263,  p.  40),  who  says: 

' '  Do  you  suppose  that  there  always  exist  in  these  organs  pain  nerves,  and 
that  only  once,  perhaps,  in  a  lifetime,  these  filaments  are  to  be  roused  into  activ- 
ity?" He  further  says:  -"As  regards  the  skin,  how  shall  we  deal  with  the  like 
dilEculty  if  we  choose  to  believe  that  everywhere  are  peculiar  nerve  fibers  de- 
voted only  to  transmitting  painful  sensations?"  So  he  concludes  that  pain  is 
not  a  "distinct  sense,  with  afferent  tracks  peculiar  to  itself,"  but  that  it  is 
"the  central  expression  of  a  certain  grade  of  irritation  in  any  centripetal 
nerve."  He  goes  on  to  say  (p.  48)  that  if  a  nerve  is  cut,  and  "the  nerve  ends, 
having  been  allowed  to  cicatrize  without  union,  should  be  constantly  irritated 
by  imprisonment  in  the  hard  tissue  of  stumps  or  scars,  or  by  a  neuritis,  a  great 
variety  of  peculiar  sensations  are  felt,  such  as  the  feeling  of  being  tickled,  of 
motion  in  the  lost  or  disconnected  part,  heat,  cold,  etc.  These  facts  seem  to 
prove  that  some  peculiar  peripheral  arrangement  for  the  production  of  touch, 
sense  of  movement,  and  the  like,  is  without  firm  physiological  foundation." 

The  last  example  is  hardly  to  the  point;  yet,  at  the  time  of  writing,  it 
was  well  taken.  To-day  it  is  recognized  that,  upon  irritation  of  a  nerve,  the 
pain  is  referred  to  the  peripheral  distribution  of  that  nerve  because  the  brain 
cells  have  learned  to  interpret  such  a  stimulus  as  coming  from  a  particular 
area,  and  will  so  continue  to  interpret  it  when  the  direct  communication  with 
that  area  is  interrupted ;  so  that  irritation  applied  in  the  course  of  a  nerve 
is  always  felt  as  though  it  were  coming  from  the  peripheral  distribution. 

One  of  the  strongest  advocates  of  special  nerves  of  pain  is  von  Frey,  who 
gives  the  following  reasons  for  his  belief: 

(1)  "By  observing  certain  precautions,  mechanical  stimulation  of  the 
skin  with  a  bristle  produces  a  pure  sensation  of  pain,  without  any  prelimi- 
nary or  accompanying  sensation  of  pressure. 

(2)  "If  a  bristle  be  placed  over  a  pressure  point,  the  sensation  appears 
immediately,  but  at  once  fades  away  again,  and  usually  becomes  unnoticeable 
after  a  short  time.  Over  the  pain  point,  the  effect  appears  later,  gradually 
increases  in  strength,  and  decreases  again  after  reaching  a  maximum. 

(3)  "When  the  head  of  a  pin  is  pressed  for  a  moment  into  the  skin  there 
follows  very  often,  after  the  sensation  of  pressure,  and  separated  from  it  by 
an  appreciable  interval,  the  sensation  of  pain." 

Von  Frey  claims  that  on  the  back  of  the  hand,  over  the  metacarpus  of 
the  ring  finger,  sixteen  pain  points  can  be  demonstrated  as  against  two 
pressure  points.  The  nerve  endings  which  convey  pain  are,  he  believes,  prob- 
ably the  free  intraepithelia  nerve  endings  (Tigerstedt 's  "Physiology,"  p.  467). 


CONVEYING   CHANNELS   FOR   SENSATIONS  37 

The  channels  for  conveying  sensibility  are  divided  into  super- 
ficial and  deep  sets  (Head  and  Thompson,  206).  The  superficial 
set  is  again  divided  into  two  others,  the  protopathic  ^  and  the  epi- 
critic.  These  differ  from  each  other  principally  in  their  power  of 
conveying  degrees  of  stimuli,  the  epicritic  being  finer,  and  capable 
of  conveying  slighter  degrees  of  stimuli.  It  is  probably  a  later 
evolutionary  development  than  the  other.  Pitt  (530)  states  that 
it  is  developed  after  birth.  According  to  Head,  Rivers,  and 
Sherren  (85),  Head  and  Sherren  (86),  and  Head  and  Thompson 
(206),  the  systems  for  conveying  sensations,  with  the  stimuli 
"which  they  carry,  are  as  follows: 

I  II  III 

System  of  System  of  System  of 

Deep  Sensibility  Peotopatiiic  Epicritic 

Sensibility  Sensibility 

Deep  pressure,  which,  Painful     cutaneous  Light  touch. 

when  excessive,  is  stimulations.  Character  of  touch. 

interpreted  as  pain.  Extremes  of  heat  and  ]^umber  of  points  of 

Localization  of  pres-  cold  (below  20°  C.  pressure. 

sure.  and  above  45°  C).  Distance    points    are 

Alterations     in     the  Visceral  sensation.  apart. 

positions     of     the  Painful      sensation  Chara.cter  of  surface 

joints,  muscles  and  from  a  prick.  touched. 

tendons.  Electrical  stimula-  Slight  differences  in 

tion.  temperature. 

Wiindt  (Strong,  437)  assumes  that  in  the  peripheral  nerves  the  paths  of 
pain  impulses  are  the  same  as  those  of  touch,  heat  and  cold  impulses.  When 
tactile  or  temperature  impulses  reach  the  cord  they  find  two  paths  open:  a 
primary  path,  leading  through  the  white  matter,  and  a  secondary  path,  or 
paths,  leading  through  the  gray  matter.  Impulses  of  moderate  intensity  take 
the  primary  path,  and  this  path  can  accommodate  only  moderate  impulses. 
When  excessive  impulses  come,  they  overflow  into  the  secondary  paths  and 
pass  upward  through  the  gray  matter.  Funke  and  Goldscheider  ("uber  den 
Schmerz, "  p.  19)  agree  with  the  assumption  that  each  nerve  carries  two  sets 
of  impulses,  one  giving  rise  to  the  ordinary  correlated  sensations,  and  the  other 
producing  pain. 

The  very  full  discussions  of  Head  and  Holmes  {Lancet,  January,  1912) 
give  the  latest  summary  of  these  studies.  * 

1  Goldscheider  (62b)  holds  that  the  protopathic  system  does  not  exist,  and 
that  the  so-called  protopathic  sensibility  is  but  an  expression  of  the  lessened 
functional  power  of  the  nerve  apparatus. 


38  THE   NATURE    OF    PAIN 

According  to  Head  and  Rivers,  the  fibers  conveying  deep  sensi- 
bility accomj^any  the  muscular  branches  of  the  nerves,  and  are 
distributed,  in  many  cases,  to  the  deeper  tissues  and  the  tendons 
of  the  muscles.  This  is  in  accordance  with  the  anatomical  find- 
ings of  Sherrington  (205,  pp.  255-256),  v^^ho  says  that  ''^macro- 
scopic nerve  trunks  are  not  purely  motor,  but  are  sensorimotor 
or  purely  sensory.  Such  nerves  as  the  phrenic,  hypoglossal,  re- 
current laryngeal,  and  posterior  interosseous  contain  an  abundance 
of  fibers  from  sensory  ganglia."  In  muscles,  the  special  end 
organ  for  root  ganglia  fibers  is  called  a  muscle  spindle  (Kuhne). 

The  nerve  fibers  conveying  these  different  sensibilities  do  not 
all  converge  into  the  same  nerve  or  roots,  although  the  fibers  con- 
veying the  same  sensation  from  the  same  part  of  the  skin  do  so,  as 
a  rule.  For  instance,  the  protopathic  fibers  from  the  same  area 
converge  and  are  all  found  in  the  sam.e  posterior  roots.  As  a  con- 
sequence, in  root  injury  (diagnostic  point  for  root  injury)  they 
do  not  overlap,  while  the  epicritic  fibers  do,  being  conveyed,  prob- 
ably, by  several  roots  and  first  being  merged  in  the  cord. 


*%  Deep,  epicritic  and  pro- 
topathic sensation. 


Epicritic  and 
protopathic    sensi- 
bility. 


Fig.  5. — ^Areas  of  Epicritic  and  Protopathic  Sensibility. 

In  the  accompanying  drawing  is  seen  the  effect  of  injury  of 
the  sacral  plexus  below  the  point  where  it  is  joined  by  the  second 
sacral  nerve.  The  third  sacral  nerve  had  been  destroyed,  and  the 
nerves  were  bound  up  in  a  dense  mass  of  fibrous  tissue  (Head 
and  Thompson,  p.  552).  This  illustrates  the  effect  of  injury  to 
the  peripheral  nervous  system  before  the  fibers  have  been  joined 
into  separate  conduction  paths  in  the  cord.  These  conduction 
paths  for  pain,  muscle  sensibility,  touch,  and  pressure  are  separate 
and  distinct.     This  is  illustrated  in  Tie;.  G,  taken  from  Head  and 


CONVEYING    CHANNELS    FOR    SENSATIONS 


39 


Thompson,  which  shows  the  effect  of  injury  to  the  pain-conduc- 
tion paths  in  the  oord. 

The  painful  impulses  from  the  skin  enter  the  cord  by  way  of 
the  protopathic  system.     They  probably  become  combined  at  once, 


Fig.  6. — Effect  of  Injury  to 
THE  Pain-conduction  Paths 
IN  THE  Cord. 

In  the  shaded  area  the  parts 
were  insensitive  to  all  painful 
stimuli,  while  at  the  same  time 
they  were  sensitive  to  light 
touch  and  pressure.  (From 
Head  and  Thompson,  206.) 


Fig.  7. — Unilateral  Complete  Lesion 
on  One  Side  of  the  Cord  Produc- 
ing A  Narrow  Band  of  Anesthesia 
on  the  Same  Side  at  the  Level  of 
THE  Lesion  and  a  Broader  Zone  op 
Anesthesia  on  the  Opposite  Side 
Slightly  Below  the  Level  of  the 
Lesion.  (FromEdinger,  Nervosen  Zen- 
tralorgane,6  Auflage,  p.  377,  Fig.  263.) 


and  enter  the  intramedullary  system  at  the  level  of  their  entrance. 
The  fibers  from  the  deep  system  do  not  enter  by  the  same  posterior 
roots  as  those  conveying  painful  cutaneous  stimuli.  Thus,  more 
than  one  segment  of  the  cord  is  required  before  all  the  painful 
impulses  from  any  one  part  of  the  body  can  be  gathered  together 
and  recombined.  After  being  recombined,  they  pass  across  the 
commissure  to  the  opposite  side,  where  they  ascend  in  the  tractus 
spinothalamicus  et  tectalis.  The  decussation  takes  place  in  the 
course  of  four  or  five  spinal  segments  (Piltz,  40Y).  According 
to  Camp,  it  may  take  six  1o  eight.  This  peculiarity  of  structure 
accounts  for  the  irregular  distribution  of  pain  sensation  in  uni- 


40 


THE  NATURE   OF  PAIN 


lateral  lesions  of  the  spinal  cord.  If  the  lesion  is  not  extensive 
enough  to  involve  all  the  fibers  coming  from  a  part,  there  may 
be  a  very  indefinite  loss  of  sensation ;  but  if  the  lesion  is  extensive, 
there  is  a  definite  loss  of  sensation  in  an  area  above  and^n  in- 
definite loss  below  the  lesion,  while  on  the  opposite  side  of  the 
body  the  sensations  are  entirely  abolished  below  the  level  of 
the  lesion.  Fig.  7,  from  Edinger,  shows  nicely  the  sensory  results 
following  a  unilateral  lesion  of  the  cord. 

In  the  accompanying  drawing  an  effort  is  made  to  illustrate 
the  course  of  the  sensory  fibers.  The  fibers  for  all  the  sensations 
enter  the  posterior  root  separately,  and  pass  from  thence  to  the 
cord.  In  the  ganglion,  these  fibers  come  into  relationship  with 
the  ganglion  cells,  with  which  they  are  connected,   some  of  the 


Anterior  or  motor  root. 

Posterior  ganglion  cell. 


Fig.  8. — Cross  Section  of  the  Spinal  Cord. 
This  represents  on  the  left  side  the  views  of  Dogiel  and  Snuf  on  the  course 
of  the  sensory  fibers  in  the  posterior  root;  while  on  the  right  side  is  illus- 
trated the  view  of  Donaldson  in  regard  to  the  division  of  the  sensory 
neuron. 

ganglion  cells  being  connected  with  more  than  one  afferent  fiber 
(Head  and  Thompson,  306),  It  is  in  these  ganglion  cells  that 
the  afferent  fibers  from  the  viscera  have  their  origin.  According 
to  Warrington  and  Griffith  (414),  not  more  than  two  per  cent,  of 
all  the  cells  in  the  spinal  ganglion  are  connected  with  the  viscera. 
This  accords  with  Langley's  statement  that  the  total  number  of 


CONVEYING   CHANNELS    FOR    SENSATIONS  41 

sensory  fibers  distributed  to  the  viscera  about  equals  the  number 
of  sensory  fibers  present  in  a  posterior  root.  Dogiel  and  Onuf 
found  the  axis-cylinder  processes  of  certain  cells  of  sympathetic 
ganglia  terminating  around  cells  of  a  spinal  type. 

Ludlum  suggests  that  the  visceral  nerves  may  give  off  col- 
laterals in  the  spinal  ganglia,  and  that  these,  coming  in  contact 
with  a  spinal  neuron,  may  transmit  the  stimulus  to  it.  This 
stimulus  would  then  be  perceived  as  coming  from  the  peripheral 
distribution  of  the  neuron,  in  the  distribution  area  of  which  the 
pain  would  be  perceived.  On  the  other  hand,  Donaldson  be- 
lieves that  the  peripheral  branch  of  a  spinal  ganglion  nerve  splits, 
and  that  one  of  the  branches  is  carried  to  the  somatic  distribution, 
while  the  other,  through  the  ramus  communicans,  is  distributed 
to  the  viscera.  In  this  case,  any  irritation  of  the  viscera  would 
so  alter  the  ganglion  cell  that,  if  the  irritation  were  strong, 
enough,  it  might  give  rise  to  pain;  or  if  it  were  not  severe 
enough  to  cause  pain,  it  might  produce  such  an  alteration  in 
the  cell  that  a  state  of  hypersensibility  would  ensue,  and  the 
slight  irritation  in  its  peripheral  distribution  would  then  be  per- 
ceived as  pain. 

After  the  entrance  of  the  sensory  fibers  into  the  cord,  they 
are  joined  into  well-defined  bundles,  all  the  fibers  of  a  single 
bundle  having  the  same  function.  The  fibers  entering  the  poste- 
rior cornua  may  be  defined  as  follows  (May,  397,  p.  759)  : 

(1)  Fibers  which  enter  the  post-columns,   and  then  divide 

into  ascending  and  descending  branches  from  each  of 
these  collaterals,  pass  at  various  levels  of  the  cord  and 
end  in  gray  matter  (Schultz  Col.,  430). 

(2)  Fibers  which  pass  forward  and  end  around  the  cells  of 

the  anterior  horn  (Edinger,  421). 

(3)  Fibers  passing  to  Clark's  column  (Edinger,  421). 

(4)  Fibers  which  go  to  the  cells  of  the  posterior  horn,  lat- 

eral column,  then  end  in  the  gray  matter  of  the  poste- 
rior column  of  the  same  side,  but  do  not  cross  (Rus- 
sell, 428,  Mott,  429).     These  fibers  terminate  in  the 


42  THE   NATURE    OF    PAIN 

medulla  (post-column  nuclei),  but  during  "their 
course  collaterals  and  some  main  fibers  terminate  in 
gray  matter"  (397). 
(5)  Fibers  which  pass  to  the  post-column.  Collaterals  are 
given  off  and  pass  to  cells  of  the  gray  matter,  and  end 
generally  around  cells  of  posterior  horns.  The  fibers 
themselves  terminate  around  cells  in  the  posterior  col- 
umns, and  some  extend  as  far  as  the  columns  of  GoU 
and  Burdach  in  the  medulla  (397,  p.  760). 

Fibers  arising  in  cells  of  gray  matter  are: 

(1)  Fibers  running  in  antero-lateral  columns,  same  side. 

(2)  Fibers  running  in  post-columns,  same  side. 

(3)  Fibers  branching,  one  part  running  in  the  antero-lateral 

column  of  same  side,  and  the  other  branch  passing  over 
in  anterior  commissure  to  run  in  antero-lateral  column 
of  opposite  side. 

The  above  are  primary  paths.     Secondary  paths  are  also  pres- 
ent in  the  cord.     They  are  represented  by: 

(1)  Fibers  which  arise  in  Clark's  column  of  the  same  side, 

and  run  to  the  dorso-spino  cerebellar  tract  (path  of 
Flick  and  Foville)  lying  exterior  to  the  crossed  pyram- 
idal tract,  and  anterior  to  the  post-root  fibers.  "In 
the  medulla  they  are  joined  by  a  bundle  of  fibers  from 
the  crossed  inferior  olive,  and  pass  directly  into  the 
restifonn  body,  and  thence  to  the  cerebellum"  (397, 
p.  763). 

(2)  The   ventro-cerebellar   tract   forming   part   of   Gower's 

tract,  in  which  the  fibers  arise :  (a)  In  the  cells  of  the 
posterior  horn  and  intermediate  gray  substance  of  the 
opposite  side,  (b)  In  the  cells  of  the  posterior  col- 
umn of  the  same  side.  Both  pass  up  in  the  cord  and 
brain,  and  terminate  in  the  cerebellum. 


S  —  Motor  reflex 
from  pain  to  a 
higher  level  on  the 
opposite  side. 


R — Fibers  giving 
rise  to  reflected 
pain  in  muscles. 


Q  —  Transference 
pain  to  a  higher 
level. 


P — Branch. 


O — Tracheus  spl- 
nothalamus  tac- 
talis. 


N — Ventral  spino- 
cerebellar tract. 


M — Dorsal    spino- 
cerebellar tract. 


L — Clark's  column. 


K — Muscle   and 
joint  sensation 


J — Touch  and  pres- 
sure. 


A —  Restlform 
body. 


B  —  Transference 
pain  felt  on  both 
sides. 


C  —  Transference 
pain  felt  on  op- 
posite side. 


D — Pain     felt     on 
same  side. 


E — Motor    reflex 
same  side  as  pain. 


F — Touch    and 
pressure. 


G — Transference 
pain. 


I — Temperat  ure. 


Fig.   9. — Diagrasi  Showing  Intraspinal  Course  of  Sensory  Fibers. 


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CONVEYING    CHANNELS    FOR    SENSATIONS  45 

(3)  The  fibers  of  the  tractiis  spino-thalamicus  which  arise 
in  cells  in  the  posterior  horns,  cross  over  in  anterior 
commissure  to  the  spino-thalamicus  tract,  and  pass 
upward  to  end  in  the  thalamus.  Collaterals  are  sent 
to: 

(a)  The  lateral  fillet  of  the  same  side. 

(b)  The  post-corpora  quadrigemina  of  the  same  side 

and  the  opposite  side. 

(c)  The  anterior  corpora  quadrigemina  of  both  sides. 

The  ascending  path  in  the  anterior  column  consists  of: 

(1)  Long  and  short  intersegmentary  fibers,  the  exact  origin 

and  terminations  of  which  are  obscure. 

(2)  One  set  of  fibers  which  arises  from  the  lateral  bundle, 

passes  into  the  anterior  columns,  and  thence  up  the 
cord  to  terminate  in  the  inferior  olive  (May,  397, 
Dydynski,  Bechterew)! 

Figures  9  and  10  will  give  a  diagrammatic  idea  of  the  course 
of  these  fibers. 

After  passing  through  the  mesial  fillet  the  fibers  enter  the 
thalamus  (May,  397,  pp.  789-791),  from  whence  they  are  dis- 
tributed to  the  cortex,  some,  at  least,  posterior  to  the  central  fissure 
of  Eolando  (397). 


CHAPTER  III 

DISTEIBUTION  OF  THE  SENSATION  OF  PAIN 

The  sensation  of  pain  is  either  deep-seated  or  superficial. 
When  deep-seated,  it  is  carried,  as  a  rule,  by  the  nerves  of  deep 
sensibility  from  the  tendon  receptors.  These  are  termed  the  ten- 
don spindles  (tendon  organs)  of  Golgi  (Howell,  539).  They  do 
not  degenerate  after  section  of  the  anterior  roots,  and  therefore 
must  be  derived  from  the  posterior  roots  and  are  sensory  in  origin 
(Sherrington,  540).  They  are  particularly  irritated  by  anything 
which  disturbs  the  relationship  of  the  subcutaneous  structures, 
such  as  deep  pressure,  or  the  rolling  of  the  tissues  over  each  other. 
Pressure  made  on  the  skin,  raised  in  a  fold,  the  base  being  held 
tightly  between  the  fingers,  will  not  be  felt.  This  shows  that 
this  type  of  sensation  (pressure  sense)  resides  in  the  deeper  struc- 
tures, the  muscles  and  tendons  (Striimpell). 

Superficial  pain  (protopathic  system)  is  carried  by  the  cutane- 
ous nerves.  Here  the  pain  fibers  are  associated  with  those  carry- 
ing sensations  of  heat,  cold,  and  light  touch.  These  sensations  are 
all  separately  received  upon  special  nerve  receptors,  found  in 
the  skin  in  well-defined  minute  areas,  each  area  being  associated 
with  a  particular  specific  sensation.  That  the  nerve  fibers  for 
temperature  and  pain  are  closely  associated  in  the  same  nerve 
bundle  is  seen  from  the  fact  that,  if  either  of  them  is  irritated, 
the  pain,  if  referred  to  a  distant  area,  is  felt  in  the  same  area 
(Rivers  and  Head,  86,  p.  417).  These  local  areas  of  sensibility, 
in  which  the  pain  fibers  originate,  "vary  greatly  in  activity  and 
threshold."  According  to  von  Prey,  the  pain  points  are  those 
pain  spots  of  lowest  threshold  in  any  particular  area  of  the  skin. 
Landois  (541)  states  that  the  pain  points  do  not  coincide  with 
46 


DISTRIBUTION   OF   THE   SENSATION   OF   PAIN  47 

the  pressure  points  which  are  present  on  the  same  area,  but  are 
about  one  thousand  times  more  numerous. 

The  epicritic  differs  from  the  protopathic  system,  in  that  it 
does  not  transmit  pain,  but  seems  to  be  concerned  with  the  dis- 
crimination of  the  finer  variations  of  sensation.  It  is  the  last 
sensory  system  to  appear,  being  developed  after  birth.  Following 
an  injury  to  a  cutaneous  nerve,  epicritic  sensibility  does  not  return 
until  some  time  after  the  recovery  of  the  other  types  of  sensibility. 
For  instance,  pain  returns  before  the  sensations  of  light  touch, 
warmth,  coolness  and  the  discrimination  of  two  points  of  a  com- 
pass. According  to  Head  and  Sherren  (295,  p.  163),  the  time 
necessary  for  the  return  of  sensibility  in  the  following  systems 
after  section  of  a  cutaneous  nerve   is  as  follows: 

Pkotopathic  Epicritic 

Begun     Completed  Begun     Completed 
Ulnar,     with     dorsal 

branch  intact ?    days     133  days  183  days     320  days 

Complete  ulnar  nerve.    109  days     171  days  169  days     278  days 

Median  nerve    65  days     190  days  262  days     387  days 

Median    and    ulnar 

nerves    101  days     21 Y  days  271  days     470  days 

A  peculiarity  of  pain  sensibility  is  that,  in  the  absence  of  ther- 
mal sensibility,  a  temperature  between  40°  and  44°  C.  will  cause 
pain ;  but  as  soon  as  the  thermal  sense  returns  it  requires  a  higher 
degree  of  stimulation  to  overcome  the  inhibition  of  the  convey- 
ance of  the  pain  stimulus  by  the  conducting  apparatus  normally 
resident  in  the  part.  The  protopathic  nervous  system  gives  rise 
to  hyperalgesia,  but  the  areas  of  hyperalgesia  derived  from  dif- 
ferent nerves  so  overlap  that  they  are  useless  as  a  means  of 
defining  the  distribution  of  any  peripheral  nerve.  On  the  other 
hand,  the  epicritic  nervous  system  gives  well-marked,  delimited 
areas  which  may  be  used  to  define  sensory  nerve-distribution  areas. 
This  means  of  discrimination  can  only  be  used  when  the  lesion 
is  in  the  course  of  a  nerve.     When  it  is  in  the  nerve  root,  the 


48  DISTRIBUTION    OF    THE    SENSATION    OF    PAIN 

regions  of  distribution  greatly  overlap  (Tigerstedt  and  Sher- 
rington), so  that  the  "lateral  aspect  of  the  body  is  provided  with 
a  twofold,  or  even  a  threefold  nerve  supply." 

Pain  Localization. — To  localize  pain,  it  is  necessary  that  the 
sense  of  touch  remain  intact.  When  it  is  diminished,  there  is  a 
tendency  for  the  sensorium  to  refer  the  pain  sensation  to  a  part 
where  the  touch  sensation  is  more  acute.  An  aid  which  the  patient 
instinctively  uses,  in  his  attempt  to  localize  sensation,  is  motion. 
Let  the  sense  of  touch  in  a  finger  be  dulled,  for  instance.  One 
may  then  prick  the  finger,  and  the  patient  will  not  be  able  to  tell 
from  where  the  pain  comes;  but  grant  him  the  privilege  of  mov- 
ing the  finger,  ever  so  little,  and  the  touch  upon  his  finger,  and  the 
pressure  against  it  of  the  pricking  object,  will  enable  him  correctly 
to  localize  the  site  of  the  irritation.  This  localization  is  explained 
in  the  work  of  Head  and  Sherrington  (263,  p.  185),  who  find  that 
the  muscles  have  a  slightly  different  sensation  from  the  skin, 
and  also  that  the  muscles  are  not  supplied  by  the  same  nerve 
fibers  which  supply  the  skin,  so  that,  by  means  of  this  involved 
muscular  supply,  a  correct  localization  can  be  made.  When  a 
lesion  is  on  the  nerv^e  circuit,  a  correct  localization  of  the  in- 
jury is  made  by  means  of  the  nervi  nervorum,  as  in  a  case  re- 
ported by  Mitchell  (263,  p.  193),  wherein  "a  blow  had  fallen 
on  the  ulnar  nerve  at  the  elbow.  The  pain  was  felt  in  the 
fingers,  but  there  was  also  a  well-defined  sense  of  hurt  at  the  point 
struck." 

However,  every  portion  of  the  body  is  not  equally  supplied 
with  pain  filaments.  The  abdomen  seems  to  be  most  liberally 
supplied,  then  the  chest,  extremities,  neck  and  back  (Crile,  521). 
The  structure  which  is  probably  the  most  sensitive  to  pain  is 
the  conjunctiva  of  the  eye. 

When  the  patient  himself  subjectively  localizes  a  pain,  one 
should  always  insist  upon  his  being  definite  in  his  statements,  and, 
if  possible,  have  him  indicate  Avith  his  hand  the  area  affected.  In 
some  cases,  the  pain  occupies  an  extensive,  but  rather  indefinite, 
area,  so  that  the  patient  is  unable  to  delimit  it  exactly.  In  these 
cases  (Schmidt)    the  focus  is  generally  at  the  point  where  the  pain 


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DISTRIBUTION   OF    THE   SENSATION    OF    PAIN 


first  occurred   (inflammatory  pain).     This  is  true  only  of  local 
pains ;  other  varieties  will  be  described  later  in  the  text. 

According  to  Tigerstedt,  Pryer  and  Krause  have  asserted  that 
the  skin  covering  any  given  muscle  is  supplied  with  sensation  by 
the  same  spinal  nerve  which  supplies  the  muscle.^  This  was  also 
a  dictum  of  Hilton ;  but  it  has  been  shown  to  be  untrue  by  Sher- 
rington. He  found  that,  during  development,  certain  displace- 
ments occur,  causing  the  skin  regions  to  be  situated  somewhat 
more  distally  than  the  muscles  with  which  they  are  related  through 
a  common  nerve  supply. 


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Cutaneous    Distribution    of    Peripheral    Nerves.     (After 
Fowler.) 

The  sensory  nerves  of  a  muscle  probably  belong  to  the  same 
cord  segment  as  the  motor  nerves  of  the  same  muscle. 

In  the  peripheral  distribution  of  the  sensory  fibers,  four  dif- 
ferent areas  must  be  defined,  namely : 

^  Tigerstedt  gives  the  flexor  surface  of  the  thigh  and  foreleg  and  the  an- 
terior side  of  the  arm  as  the  only  exceptions  to  this  rule. 


DISTRIBUTION    OF    THE    SENSATION    OF    PAIN 


51 


(1)  The  areas  of  distribution  of  the  peripheral  nerves. 

(2)  The  areas  of  distribution  of  the  different  plexuses. 

(3)  The  areas  of  distribution  of  the  posterior  roots  and  their 

corresponding  segments. 

(4)  The  areas  of  distribution    of    certain    areas    related    to 

visceral  disease,  as  defined  by  Head  and  his  associates. 


Fig.  13. 

Figs.  13  and  14. — Cutaneous  Nerve  Supply,  Showing  the  Distribution 
Areas  of  the  Different  Plexuses.  (Toldt,  Part  VI,  p.  811.) 

The  area  of  distribution  of  the  sensory  fibers  in  the  peripheral 
nerves,  because  of  their  overlapping,  is  rather  difficult  to  outline. 
This  accounts  for  the  great  variation  in  boundaries,  as  given  by 
the  leading  workers  in  this  field.  Figures  13-17  are  a  composite 
of  the  description  and  the  drawings  (see  figures)  of  the  principal 
authors  consulted. 

Any  lesion  causing  irritation  in  the  course  of  a  peripheral  sen- 
sory (pain)  nerve  would  cause  the  pain  to  be  refen-ed  to  the  dis- 
tribution area  of  this  nerve.  Care  must  be  taken,  however,  not  to 
allow  the  overlapping  of  the  distribution  areas  to  render  the  de- 
ductions misleading. 

The  distribution  areas  of  the  sensory  fibers  in  the  posterior 
roots  and  in  the  corresponding  segments  of  tlie  cord,  as  given  by 


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52 


eOMMUNICATlNO 
BR  TO  SACHAL  (iAN«l 
LSYMPATMET 


euuTeus  meoius 

jS'\j)tEUS  MINIMUS 

'     TENSOR  FASCIA  FtHORI* 


SKIN  oveA 

&UUTE.U5 

MAXIMUS 


HETAnaftSOf  TARSAL  J01NT5 

PmlanGIMT.I  MET.4.PHAL.* 

JOINTS. 2J.»  TOES 


Fig.   16. — Disteibution  of  the   Nerves  Derived  from  the  Sacral 

Plexus. 


53 


54 


DISTRIBUTION    OF    THE    SENSATION    OF    PAIN 


different  authors,  differ  even  more  widely  than  do  those  of  the 
peripheral  nerves.  The  distribution,  as  given  by  Thorburn,  Starr, 
and  Kocher,  is  shown  in  Figures  18-23.  Figure  23  shows  the 
relationship  between  the  cord  segments  and  the  different  nerves. 


lnte9.Chest  ^^v-"- -V. 


Inteq.Chest  ^c" 
4  Abdomen  ^\n"" 


Multifidus 
5pmae 


inbeq.BacK 


Longissimus 

Dors  I 
Iliocostals 


Buttocks 

Fig.  17. — Dorsal  Nerves. 

There  are  also  on  the  body  surface  certain  well-defined  zones 
which  are  related  to  visceral  diseases ;  they  were  first  described 
by  Head,  who,  while  working  in  the  London  Hospital,  noticed 
that,  in  different  diseases  of  the  viscera,  areas  or  zones  of  cu- 
taneous hyperalgesia  were  found  which  coincided  rather  closely 
with  the  areas  of  distribution  of  herpes  of  the  different  regions. 
Since  herpes  was  due  to  a  disease  of  the  posterior  root  ganglion 
(Head  and  Rivers;  Church,  542,  etc.),  he  concluded  that  in  the 
ganglion  certain  stimuli  must  be  transmitted  from  the  visceral 
fibers  to  those  going  to  the  somatic  areas,  and  produce  an  irrita- 


0.2- 


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Fig.  18. — Cord  Zones  According  to  Kocher. 
These  represent  the  cutaneous  areas  involved  in  lesions  of  different  segments 
of  the  cord.  The  circles  represent  the  areas  of  maximum  tenderness 
according  to  Head.  Head's  zones  and  these  do  not  entirely  coincide 
because  Head  worked  out  his  zones  from  a  study  of  visceral  lesions  and 
somewhat  arbitrarily  defined  them,  while  Kocher  used  the  peripheral 
disturbances  occurring  in  lesions  of  the  cord  as  the  means  of  defining  his 
segments.  These  really  represent  the  distribution  areas  of  the  posterior 
roots. 


55 


Supraclavicular,  3,  4,  C. 


Circumflex,  5,  6,  7,  8,  C. 
Intercoatohumeral. 


Nerve  of  Wrlsberg,  1,  D. 


External  cutaneous. 
Internal  cutaneous,  8,  C,  1,  D. 


Musculocutaneous,  5,  6,  7,  C 
Iliohypogastric,  1,  I.. 

Ilioinguinal,  1,  L. 

Genitocrural,  1,  2,  L. 

Median.  6,  7,  8,  O,  1,  D. 

External  cutaneous,  2,  3,  L. 

Middle  cutaneous,  2,  3,  4,  L. 
Internal  cutaneous,  2,  3,  4,  L. 

Plexus  patellae. 
Internal  saphenous,  2,  3,  4,  L. 

Branches  from  external  pop- 
liteal, 4,  S.L.I.  2,  3.4.  S. 


Musculocutaneous,  4,  5.  L,  1, 

2.  3.  4,  S. 
External    saphenous,  4,  5.  L, 

1.  2,  3,  4.  S. 
Anterior  tibial,  4,  5,  L,  1,  2,  3, 

4,  S. 


M...\ 

^^^     ' 

^B\  •• 

i^V\ 

3^\/  \ 

M)" 

Fig.  19. — Cutaneous  Areas  Related  to  Spinal  Cord  Segments  (Church  and 
Peterson,  p.  56,  after  Starr)  and  Cutaneous  Distribution  of  Nerves 
(Church  and  Peterson,  p.  52,  after  Fowler). 


56 


,.-^-tf.  to  rfefiu  tattralh 
——to  rectut  anile,  mlnop 

..AnatlomotU  ullh  hypoglouat 

■ Anaslomottt  ulth  pnrunogailrfc 

.___^.  lo  reelua  anUc.maJor. 
.__//'.  lo  maatoid  rej/ton. 

Orrat  auricular  n. 

• Tranavtrtc  cervical  n. 

Hai}.W.  to  Traptzlu*,  Ang.  Scop.  andBhomboU. 

Supra  ctavleutar  n, 

Supra^cromiat  n. 

PhreitU  n. 

N.  to  levator  ang.  teap- 

M  to  rhomboid 

Suth-vapular  lu 

.^Subclavicular  n. 


.—./r.  teputtralUmaia 


SfuKulooifaiicoiiJ  n. 

Median  n. 

Kadlatn. 

.l/fnorn. 

_/fi(emol  c%tian€OUS  n. 
I____^__  .  AnaU  Mtmal  eiiCaiuOM  a. 


,  nto^ypooatlrle  n. 
..ntoJngutnaln. 

:..Xxter7ial  eataneow  ". 
,_Oen((»cniral  IL 


Antcrtar  cmralti^ 
,___06turafor  r. 


K.  toXevater  an! ^<a-V 

Jf.  to  obturator  Int ^^-X 

K.  lo  ophlncler  ant. 

Coccygeal  n... 

Co.l 


^^.Suptrtor  gMiat  n. 


v.  to  pyrtformt*' 

-^If.  to  gemtllut  tuptr- 

N.  to  gemelli/i  Infer. 

If.  lo  guadratut 

Small  actallo  n. 
.a-jlatte  n. 


Fig.   23. — Relationship  of  the  Segments  of  the  Spinal  Cord  and 

Their  Nerve  Roots  to  the  Bodies  and  Spines  of  the  Vertebra. 

This  is  the  reason  for  the  location  of  the  distribution  segments  lower  than  one 

would  naturally  expect.     (Keen's  System,  Vol.  II,  p.  843.) 


68 


Fig.  24. — Cord  Zones  Fig.  25. — Cord  Zones  and  Areas  Fig.  26. — Cord  Zones 
AND  Areas  of  Max-  of  Maximum  Tenderness  Ac-  and  Areas  of  Max- 
imum Tenderness  cording  to  Head.  imum  Tenderness 
According  TO  Head.  According  to  Head. 


69 


60  DISTRIBUTION    OF    THE    SENSATION    OF    PAIN 

I 

tion  of  these  fibers,  so  that  lighter  than  ordinary  stimuli  give  rise 
to  pain.  These  areas  are  given  in  Figs.  24-26.  At  the  present 
time,  they  are  acknowledged,  in  the  main,  as  correct;  and  while 
many  have  slightly  modified  the  areas,  the  modifications  are  so 
slight  and  so  varied  that  it  has  been  thought  better  to  reproduce 
the  original  drawings  of  Head. 


CHAPTEK  IV 

PEECEPTION  OF  PAIN  SENSATION 

There  are  two  states  of  perception,  or  rather,  degrees  of  inter- 
pretation, of  pain-sensation,  namely:  (1)  The  condition  or  state 
in  which  sensation  is  almost  or  entirely  absent,  anesthesia  (when 
the  sensibility  to  pain  alone  is  absent,  it  is  called  analgesia),  and 
(2)  the  state  in  which  sensation  is  more  acute  than  normal,  and 
in  which  the  slightest  irritation  will  produce  a  more  pronounced 
reactio"n,  or  hyperesthesia  (if  the  pain  reaction  alone  is  increased, 
it  is  called  hyperalgesia).  Intermediate  between  these  two  is  a 
class  of  conditions  producing  symptoms  not  severe  enough  to  be 
classed  as  hyperesthesia,  but  which,  because  of  their  peculiarity, 
cannot  be  classed  as  normal.  These  are  the  paresthesias,  in  which 
creeping  sensations,  etc.,  are  present  over  a  part. 

Analgesia. — Analgesia  may  be  either  central  or  peripheral. 
When  central,  the  lesion  may  be  in  the  brain,  or  spinal  cord. 
When  it  is  in  the  brain,  it  may  be  either  endogenous  or  exogenovs. 
Endogenous  analgesia  is  present  during  severe  emotion,  such  as 
great  joy,  anger,  and  fear,  as  is  seen  in  the  disappearance  of  a 
toothache  as  soon  as  the  patient  enters  the  dentist's  office,  or  the 
cessation  of  pain  when  the  patient  is  in  mortal  terror.  It  may 
be  present  during  arduous  mental  work  which  requires  great  con- 
centration of  thought,  and  also  in  states  of  mental  exaltation, 
such  as  exhibited  by  religious  zealots,  examples  of  which  are  the 
Buddhist  fakirs.  In  such  cases,  a  perversion  of  sensation,  from 
strong  religious  excitement,  seems  to  have  taken  place,  so  that, 
while  undergoing  the  most  severe  tortures,  no  pain  is  felt.  In- 
stead even  a  sensation  of  pleasure  is  experienced.  Just  what 
factors  underlie  this  type  of  phenomena  is  far  from  being  satig- 

61 


62  PERCEPTION    OF    PAIN    SENSATION 

factorilj  explained.  Some  have  assumed  states  of  localized 
anemia  or  hyperemia  consequent  upon  variations  in  blood  pres- 
sure. Others  assume  changes  in  the  resistance  to  the  passage  of 
nervous  energy  in  completing  nerve  paths.  Others  assume  a 
"spill"  hypothesis,  namely,  that  emotional  excitement  lowers  the 
tension  in  certain  nerve  paths,  and  thus  drains  off  the  sensory  im- 
pulses, so  that  the  nerve  is  not  able  to  properly  conduct  the  stimu- 
lus, and  radiation  takes  place  into  the  adjacent  tissues.  Again, 
others  assume  blocking  processes  which  shut  the  sensory  percep- 
tions out  of  consciousness.  Thought  along  these  lines  is  in  a 
state  of  flux.     ISTothing  is  definitely  known. 

Toxic  Analgesia. — Certain  forms  of  toxemia  are  powerful 
in  retarding  the  perception  of  pain.  They  produce  a  dulling  of 
consciousness,  varying  all  the  way  from  cloudiness  of  intellect 
to  unconsciousness.  Such  toxemias  are  found  in  many  statos 
and  diseased  conditions  of  the  body,  as  acute  infectious  diseases, 
the  terminal  stages  of  malignant  processes,  uremia,  acute  yellow 
atrophy  of  the  liver,  etc.  They  are  also  present  in  cases  of  failing 
circulation,  such  as  occur  prior  to  death,  in  fainting,  and  after 
severe  hemorrhage.  This  is  hardly  the  place  to  speak  of  the 
mentally  defective,  who,  because  of  retarded  development  of  the 
perceptive  faculties,  are  backward  in  their  ability  to  experience 
pain.  These  states  are  found  in  idiocy.  In  psychoses  of  various 
types,  also,  the  pain-perceptive  centers  are  dulled. 

VoLDNTAKY  Analgesia. — In  somc  cases,  there  seems  to  be 
an  ability  to  inhibit  pain-perception,  as  is  seen  in  a  case  reported 
by  Witmer,  of  a  "professional  painless  man."  In  this  case,  pins 
and  needles  could  be  pushed  into  the  skin;  also,  he  could  hold  a 
red-hot  half-dollar  in  his  hand  without  wincing,  until  it  had 
burned  itself  deep  into  the  flesh.  Witmer,  from  a  consideration 
of  the  circumstances  of  the  case,  believed  that  the  subject  inhibited 
the  sensation  of  pain,  and  not  its  external  manifestations;  that 
is,  that  he  did  not  perceive  the  pain,  and  was  not  stoically  en- 
during it.  The  patient  was  possibly  a  syringomyelic.  Many  of 
us,  by  sufficient  training,  are  able  to  inhibit  the  sensation  of  pain. 
According  to  Mitchell,  some  women  remain  for  years  without  the 


ANESTHESIA  83 

peripheral  pain  sense,  though  the  general  health  is  unimpaired, 
while  the  internal  organs  are  still  sensitive  to  pain,  and  all  forms 
of  skin  sense  are  as  keen  as  ever. 

The  extrinsic  or  exogenous  causes  acting  to  produce  analgesia 
are  all  those  conditions  which  produce  a  lowered  pain  perception. 
Chief  among  these  are  drugs,  morphin  and  ether  probably  taking 
the  highest  place  among  them.  Both  act  by  obtunding  conscious- 
ness, although  either  may  cause  analgesia  before  consciousness 
has  entirely  disappeared. 

Anesthesia. — It  is  often  a  subject  of  controversy  whether  or 
not  a  patient  feels  pain  while  under  an  anesthetic.  It  seems 
foolish  that  svich  a  controversy  should  arise,  when  we  know  that 
pain  is  a  concept  of  the  higher  sensorium,  and  that  as  soon  as 
consciousness  is  dulled  the  sensorium  becomes  inactive,  and  the 
body  is  unable  to  perceive  pain,  although  it  may  be  able  to  per- 
ceive touch.  To  illustrate  this,  I  will  recount  a  little  personal 
experience  of  several  years  ago.  After  using  ethyl  chloride  suc- 
cessfully upon  a  patient.  Dr.  Henry  Hall  suggested  that  I  try 
some.  This  I  did,  and  after  a  few  seconds  the  surroundings 
seemed  to  become  distant,  and,  while  I  could  see  and  hear,  I 
was  unable  to  move.  'When  the  doctor  touched  me  and  asked 
me  to  tell  him  when  he  did  so,  I  was  unable  to  intimate  by  word 
or  gesture  that  I  did  not  feel  him,  although  I  could  see  him 
touching  me. 

Anesthesia  is  in  reality  an  inliihition  of  perception.  The  physi- 
ologists are  agreed  that  the  first  phenomenon  which  is  abolished 
during  anesthesia  is  that  of  voluntary  movement,  after  which  come 
the  loss  of  spinal  reflexes,  loss  of  pain,  and  finally  loss  of  con- 
sciousness. It  is  also  agreed  that  loss  of  pain-perception  precedes, 
by  a  noticeable  interval,  loss  of  consciousness.  Crile  is  not  in 
accord  with  this,  for  he  believes  that  the  only  result  of  an  anes- 
thetic (ether)  is  obtunded  consciousness.  The  disturbing  stimuli 
from  the  irritated  area  are  carried  to  the  brain,  just  as  though 
the  patient  were  conscious,  and  exert  the  same  irritative  action. 
The  only  difference  is  that  the  patient  is  not  aware  of  their 
presence. 


m 


PERCEPTION    OF    PAIN    SENSATION 


Interference  T\'ith  the  areas  of  pain-perception  will  also  cause 
a  loss  of  pain-perception.  This  is  seen  especially  in  all  those  cases 
in  which  pressure  is  made  upon  the  pain-centers,  as  in  tumors, 
hemorrhage,  or  pressure  from  a  depressed  fracture  of  the  skull.  A 
case  of  this  kind  was  reported  hy  LeszjTisky   (550),  in  which, 

after  a  fracture  of  the 
skull,  there  developed, 
along  with  motor  symp- 
toms, an  anesthesia  ex- 
tending around  one  leg. 
It  resembled  an  hysterical 
anesthesia  in  that  its  boun- 
daries were  transverse, 
and  did  not  in  the  least 
resemble  the  boundaries  ol 
the  areas  of  distribution  of 
either  the .  peripheral  sen- 
sory nerves,  the  posterior 
roots,  or  the  cord  seg- 
mental zones  (Fig.  27). 
In  this  case,  ''there  was 
an  area  of  complete  anes- 
thesia, extending  from  the 

toes  to  about  two  and  a 
Fig^27.-Areas  of  Anesthesia  on  Leg   j^^jf  ^^^^^^  ^j^^  ^^^ 

Due     to     Depressed     Iracture     of 

Skull.  tella     anteriorly,     and    to 

a.  Thermoanesthesia;  b.  tactile  and  thermo-  about   three   inches   below 
anesthesia;  c.  complete  anesthesia.  ,  i-       i 

the  popliteal  space  poste- 
riorly, with  a  circular  band  of  dissociated  sensory  disturbance 
above  this.  For  two  inches  above  the  level  of  the  complete  anes- 
thesia, the  tactile  and  temperature  sensibility  were  abolished  and 
the  pain-sense  was  preserved.  For  one  inch  and  a  half  farther  up, 
thermoanesthesia  persisted  without  impairment  of  other  forms 
of  sensibility.  The  patient  stated  that  about  one  week  be- 
fore entering  the  hospital  he  noticed  beginning  loss  of  sensi- 
bility in  the  leg,  and  that  about  two  weeks  later  the  loss  was 


ANESTHESIA  65 

complete.  The  loss  of  sensibility  to  the  application  of  the  faradic 
wire  brush  extended  from  the  toes  to  about  three  inches  below 
the  level  of  the  area  of  complete  anesthesia.  The  senses  of  po- 
sition and  of  localization  were  normal  in  the  toes  and  foot.  The 
senses  of  localization  and  of  pressure  were  absent  in  the  leg. 
The  upper  extremities  and  the  other  lower  extremity  were  nor- 
mal. There  was  no  astereognosis.  The  visual  fields  as  measured 
with  the  perimeter  were  practically  normal."  This  case  brings 
the  point  prominently  to  the  mind  that  there  are  areas  in  the 
cerebral  cortex  which  are  connected  with  the  sensory  distribu- 
tion of  different  regions  of  the  body.  This  is  important  in  the 
etiology  of  hysteria. 

Paresis  frequently  gives  rise  to  anesthesia,  which,  according  to 
Clouston,  is  due  to  loss  of  inhibition  (  ?)  in  the  cortical  areas. 
It  would  seem  more  likely,  from  the  pathology  of  this  condition, 
to  be  a  loss  of  perception  in  the  cortical  areas. 

Passage  of  an  electric  current  of  1,000  volts  through  the  body 
will  cause  anesthesia,  probably  due  to  encephalitis  causing 
inability  of  centric  perception  (Hoover,  554). 

The  peripheral  causes  of  anesthesia  are  all  those  conditions 
arising  in  the  nerve  pathways  which  act  as  obstructions  to  the  on- 
ward progress  of  the  pain  stimulus,  chief  of  which,  of  course,  is 
severance  of  the  pathways  by  section  of  the  nerves  or  spinal  cord. 
This  may  be  the  result  of  accident  or  of  design,  excepting  that,  in 
the  case  of  the  cord,  it  is  never  in  man  the  result  of  design.  In 
some  cases  the  peripheral  nerves  are  sectioned  by  the  surgeon  in 
an  attempt  to  cure  neuralgia.  This  is  an  operation  which  for- 
merly was  frequently  performed  for  trifacial  neuralgia.  Broken 
back  (fracture  of  the  vertebra)  frequently  acts  as  an  interrupter 
of  conduction,  though,  unless  it  is  accompanied  by  a  dislocation, 
it  generally  does  not  cause  a  complete  severance  of  the  cord ;  so 
that  the  anesthesia  may  not  be  symmetrical  nor  complete.  Cord 
tumor,  however,  is  almost  invariably  accompanied  by  anesthesia. 
Indeed,  Bailey  (544)  says  that  no  cord  tumor  can  be  diagnosed 
with  certainty  if  sensibility  is  intact.  The  only  exception  Bailey 
makes  is   in  tumors  of  the  cauda   equina.      Syringomyelia   ire- 


66  PERCEPTION    OF    PAIN    SENSATION 

quently  produces  changes  which  interrupt  the  conduction  of  touch, 
pain,  and  temperature.  In  other  disorders,  as  in  transverse  myeli- 
tis, a  local  interruption  of  the  sensory  tracts  in  the  cord  also 
results  in  anesthesia.  In  tabes  the  sensory  fibers  are  affected  just 
as  they  enter  the  cord,  and  analgesia  is  produced  here,  although 
touch  and  temperature  conduction  may  remain  intact.  Practi- 
cally the  only  lesion  of  the  posterior  roots  which  causes  anes- 
thesia is  severance,  which  generally  occurs  as  the  result  of  frac- 
ture of  the  vertebra. 

Lesions  within  the  nerve  itself  may  cause  an  anesthesia.  An- 
esthesia may  also  be  the  result  of  pressure  within  the  nerve  sheath, 
as  illustrated  in  the  case  cited  by  Babcock  (549),  of  a  patient 
who  had  sustained  a  small  incision  of  the  median  nerve  from  a 
piece  of  flying  glass  and  had  an  area  of  anesthesia  corresponding 
to  the  sensory  distribution  of  this  nerve.  On  exposure  of  the 
injured  nerve  it  was  found  that  it  was  not  divided,  but  was  the 
seat  of  a  marked  fusiform  enlargement.  Upon  incision  of  the 
affected  area,  a  gelatinous,  serous  fluid  flowed  from  between  the 
nerve  fibers.  A  free  longitudinal  incision  was  made  into  the 
nerve.  Four  days  later,  upon  testing  the  hand,  it  was 
found  that  the  area  of  anesthesia  had  decreased  one-third, 
and  that  there  was  a  distinct  increase  in  the  ability  to 
flex  the  fingers. 

Should  a  nerve  trunk  be  pressed  upon  by  a  tumor,  a  complete 
interruption  of  the  conduction  of  nervous  impulses  may  occur, 
and  the  area  of  skin  distribution  cut  off  will  lose  all  sensibility. 
At  the  same  time  the  irritation  occurring  at  the  level  of  the  lesion 
may  cause  severe  pain,  which  is  referred  to  the  peripheral  distri- 
bution of  the  nerve.  A  similar  condition,  called  anesthesia  dolo- 
rosa, is  often  associated  with  cancer  of  the  spine,  the  mass  press- 
ing upon  and  irritating  the  sensory  nen-es  entering  the  interver- 
tebral spaces  (Eichhorst,  553,  Landois,  etc.). 

Freezing  of  a  sensory  nerve  trunk  also  causes  anesthesia. 
This  is  due  to  ischemia  because,  when  ischemia  is  present  in  a 
part  (Kofman,  478),  anesthesia  generally  results.  This,  in  turn, 
may  be  a  result  of  mechanical  pressure  or  of  a  chemical  reaction 


HYPERALGESIA 


67 


to  toxic  factors.  In  the  Glasgow  Medical  Journal  of  1898 
(Vol.  L,  p.  467)  are  mentioned  the  following  instances  of  opera- 
tive procedure  without  pain,  the  only  anesthetic  measure  being 
the  production  and  retention  of  complete  ischemia  by  means  of  an 
Esmarch  bandage.  By  this  method,  a  ganglion  was  resected  from 
the  dorsum  of  the  right  wrist  without  pain,  a  needle  was  also  re- 
moved, and  a  ganglion  in  the  popliteal  region  was  resected.  In 
such  cases  it  is  necessary  that  the  ischemia  be  complete,  and  that 
a  short  time  shall  elapse  between  the  application  of  the  Esmarch 
and  the  beginning  of  the  operation. 

Certain  toxic  agents  (as  cocain)  will  produce  a  terminal  anes- 
thesia. Cocain  first  destroys  the  pain-conduction  power  of  the 
fiber,  and  finally  touch  sensation.  In  the  tongue,  according  to 
Schree  (201,  p.  207),  the  order  in  which  sensation  is  lost  in 
general  anesthesia  is  taste  (bitter,  sweet,  then  acid),  pressure  lo- 
calization, and  lastly  tactile  perception.  Temperature  sense  is  also 
abolished  (Met- 
tler,  505).  Car- 
bolic acid  (5  per 
cent,  solution  on 
the  tongue)  weak- 
ens the  sense  of 
pressure  and  pain, 
but  destroys  the 
sense  of  taste  and 
temperature.  Ar- 
senic and  bella- 
donna produce  an- 
esthesia to  touch 
and  pain,  but  not 
to  temperature.  Sa- 
ponin produces  an- 
esthesia to  touch, 
but  does  not  affect  pain  in  any  way  (Eebot,  Mettler,  505). 
Hyperalgesia  is  a  condition  in  which  there  is  an  abnormal 
painful   sensibility  to  irritative  processes    of    any  kind.      Since 


Fig.  28. — Method  of  Eliciting  Hyperalgesia. 


68  PERCEPTION   OF   PAIN   SENSATION 

pain-perception  is  the  specific  performance  of  a  definite  kind  of 
nerve  fiber,  hyperalgesia  may  be  regarded  as  a  hypersensitiveness 
of  the  pain  nerves  (Sahli,  p.  771). 

Hyperalgesia  of  a  part  may  be  tested  in  three  ways: 

(1)  A  rather  sharp  pin,  or  pointed  instrument,  is  drawn 
across  the  surface  under  examination,  the  instrument  being  pre- 
ceded by  the  finger,  as  shown  in  the  drawing.  The  reasons  for 
the  finger  preceding  the  instrument  are:  (a)  that  the  sense  of 
touch  may  be  somewhat  removed,  in  order  that  the  patient  may 
not  be  so  likely  to  confuse  touch  sensation  with  pain  sensation, 
and  (b)  that,  by  using  the  second  finger  as  a  support,  more 
equable  pressure  with  the  pin  can  be  made,  while  at  the  same 
time  all  folds  of  the  skin  which  might  cause  inequality  of  pres- 
sure will  be  pressed  out. 

(2)  A  second  method,  in  which  the  skin  is  pinched  between 
the  fingers,  is  also  a  good  one,  but  does  not  show  the  slight  changes 
in  sensibility  which  are  found  by  the  first  method ;  nor  does  it 
permit  of  such  fine  judgments  on  the  part  of  the  patient  as  to 
the  presence  or  absence  of  pain,  or  of  variations  in  the  degree 
of  pain,  because  of  the  inability  of  the  examiner  always  to  exert 
the  same  amount  of  pressure  in  each  individual  pinch.  As  far 
as  personal  choice  goes,  I  have  always  preferred  the  first  method. 

(3)  The  head  of  a  pin  is  sometimes  used  instead  of  the 
point.  This  really  gives  one  hyperesthesia  instead  of  hyperalgesia, 
hyperesthesia  meaning  an  increased  sensitiveness  to  all  sensation, 
and  hyperalgesia  meaning  only  an  increased  sensitiveness  to  pain. 

(4)  Instrumental. — Various  forms  of  instruments  (esthesio- 
meters,  or  algometers)  have  been  devised  for  the  purpose  of  accu- 
rately recording  changes  in  sensory  or  pain  perception. 

In  judging  of  the  hyperesthesia  of  a  part,  special  attention 
should  be  paid  to  each  of  the  tissues  composing  the  part,  namely: 

(1)  The  skin  (hyperalgesia  sought  by  running  the  point  of  a 

pin  over  the  skin). 

(2)  The  subcutaneous  tissues  (hyperalgesia  sought  by  grasp- 

ing lightly  the   structures   of   the   skin  between   the 
thumb  and  first  finger). 


HYPERALGESIA  69 

(3)  The  muscular  tissues  (hyperalgesia  sought  by  movement 

of  muscles). 

(4)  The  osseous  tissues   (hyperalgesia  sought  by  deep  pres- 

sure and  tapping), 

(5)  The  serous  membranes,  such  as  the  pleura  or  peritoneum 

(hyperalgesia  sought  by  deep  pressure,  respiratory  or 
cardiac  movement).     (McKenzie.) 

The  areas  of  hyperesthesia  of  any  two  of  these  tissues  may 
not  be  coextensive.  The  area  of  tenderness  of  the  subcutaneous 
tissues  is  generally  more  extensive  than  the  areas  of  any  of  the 
other  tissues.  Sometimes  the  areas  of  the  subcutaneous  tissues 
which  are  sensitive  may  be  at  some  distance  from  the  hyperal- 
gesic  areas  of  the  skin.  This  is  explained  by  the  fact  that  both 
of  these  areas  are  supplied  by  nerves  coming  from  the  same  seg- 
ments of  the  cord,  but  having  different  distributions  (McKenzie). 

Head  has  made  a  special  study  of  hyperalgesic  zones  of  the 
skin;  that  is,  hyperalgesia  due  to  pricking  with  a  sharp  instru- 
ment, or  by  pinching  a  fold  of  skin  between  the  fingers.  Should 
the  underlying  tissues  be  grasped,  or  pressure  be  exerted  upon 
them,  the  results  of  the  examination  are  apt  to  be  deceiving,  from 
the  fact  that  the  sensibility  of  the  subcutaneous  tissues  is  mixed 
with  that  of  the  skin.  A  reflex  associated  with  these  hyperalgesic 
zones  is  dilatation  of  the  pupil.  When  the  irritation  is  severe 
enough  to  cause  pain,  this  dilatation  is  especially  noticed  on  the 
side  which  is  hyperalgesic.  Pinching  of  the  areas  which  are  not 
hyperalgesic  may,  if  the  pinching  is 'severe  enough,  cause  a  dila- 
tation of  both  pupils,  but  more  marked  on  the  side  pinched.  The 
hyperalgesic  areas  are  particularly  insensitive  to  deep  pressure. 
In  many  cases  touch  is  not  painful,  while  in  others  it  produces 
the  most  severe  pain.  Deep  pressure  over  these  areas  will  also 
produce  a  dilated  pupil  more  pronounced  on  the  aifected  side.  In 
these  areas  the  sensations  of  heat  and  cold  are  also  exaggerated. 

These  hyperalgesic  areas  are  sharply  defined,  while  the  hyper- 
algesic areas  due  to  a  lesion  of  a  nerve  or  nerve  trunk  are  rather 
vague  and  indefinite,  and  overlap.    As  a  consequence,  they  cannot 


70  PERCEPTION    OF    PAIN    SENSATION 

be  used  to  delimit  the  boundaries  of  nerve  distributions.  The 
mere  fact  that  these  areas  of  hyperalgesia  (Referred  Pain,  Head) 
and  of  extremes  of  temperature  (Forsyth,  26,  p.  173)  do  not 
overlap,  seems  to  show  that  they  have  their  origin  in  the  cord, 
and  bear  some  relationship  to  the  pain  pathways,  or  at  least  that 
they  arise  in  the  spinal  ganglion  before  the  nerve  roots  unite  and 
form  plexuses,  for  it  seems  that  it  makes  no  difference  how  many 
nerve  plexuses  and  nerves  the  spinal  roots  form ;  the  areas  of 
hyperalgesia  are  still  distributed  on  the  body  in  a  segmental  form. 
This  is  well  illustrated  in  injuries  of  the  spinal  roots,  or  of  the 
cord.  Langley  (131,  p.  235)  thinks  that  a  slight  rearrangement  is 
required  in  Head's  areas,  in  order  to  bring  the  anatomical  and 
clinical  evidence  in  accord.  He  says  that  "a  white  ramus  always 
has  sensory  fibers."  If  so,  it  could  carry  sensory  impulses,  which 
would  be  so  interpreted  by  the  brain.  We  will  not  discuss  this 
further,  but  will  leave  it  for  consideration  under  Sensibility  of 
the  Internal  Viscera. 

In  some  cases  of  anemia,  malaria,  and  infections  of  various 
kinds,  painful  areas  are  present  in  the  skin.  This  is  particularly 
true  of  influenza,  which  sometimes  causes  a  severe  general  hyper- 
esthesia ;  so  much  so  that  the  slightest  touch  is  painful.  The 
scalp  may  be  so  affected  that  the  combing  of  the  hair  is  almost 
Unbearable.  In  some  cases  lesions  of  the  internal  viscera  give 
rise  to  no  hyperalgesia  until  an  intercurrent  infection,  such  as 
pneumonia,  or  possibly  appendicitis,  occurs.  This  increases  the 
irritability  of  the  cells  in  the  cord,  and  then  the  irritation  from 
the  diseased  focus  is  felt  and  is  referred  to  the  peripheral  distri- 
bution, and  continues  after  the  intercurrent  affection  has  disap- 
peared. 

Hyperalgesia  and  hyperesthesia  do  not  increase  the  accuracy 
of  localization.  Rather,  they  seem  to  multiply  and  duplicate  the 
number  of  sensations  (Mettler,  505),  so  that  the  patient,  on  at- 
tempting to  delimit  his  pain  areas,  becomes  greatly  confused. 

Tenderness. — Tenderness  is  slightly  different  from  hyperal- 
gesia. It  means  a  painful  condition  produced  by  pressure.  Hy- 
peralgesia, when  severe,  will  also  give  rise  to  tenderness,  but  it 


TENDERNESS  71 

may  also  be  present  and  not  give  rise  to  pain  on  pressure.  In  some 
cases,  even  a  strong,  firm  pressure  is  found  most  gratifying. 
Sometimes  there  is  a  dissociation  between  the  tenderness  and  the 
subjective  pain,  the  tenderness  being  present  over  the  site  of  the 
lesion,  while  the  subjective  pain  may  be  limited  to  this  area  or 
may  be  referred  to  a  distant  area. 

As  a  rule,  pain  of  equal  intensity  cannot  be  felt  in  two  places 
at  the  same  time,  for  the  mind  is  capable  of  only  a  single  impres- 
sion at  one  time.  Then,  it  will  be  asked,  how  are  we  aware  of 
the  pains  over  different  parts  of  the  body  during  the  course  of 
certain  diseases  (as  influenza)  ?  The  answer  is  very  simple.  As 
no  stimulus  can  always  maintain  the  same  intensity,  at  times  its 
strength  will  be  reduced.  At  such  a  time,  another  and  lighter 
stimulus  will  gain  the  ascendency,  and  will  impress  its  location 
and  character  upon  the  brain,  and  be  perceived.  This  perception 
lasts  only  a  short  time,  when  the  first,  or  some  other,  stimulus 
again  gains  the  ascendency  and  impresses  its  character  upon  the 
mentality.  Thus  the  localization  of  the  pain  varies,  from  day  to 
day,  from  hour  to  hour,  and  from  minute  to  minute,  the  stronger 
impression  being  the  only  one  of  which  the  mind  is  cognizant. 
This  also  accounts,  in  some  instances,  for  the  variability  of  pain, 
and  for  its  frequent  change  of  location.  In  other  cases,  the  ten- 
derness may  be  felt  in  a  part  distant  from  the  lesion.  This  is  par- 
ticularly true  when  disease  or  pressure  on  a  nerve  is  present. 
When  such  is  the  case  areas  of  tenderness  are  generally  at  the 
points  where  the  nerves  emerge  from  the  deeper  parts  and  become 
superficial.     To  them  the  name  Valleix's  points  has  been  given. 

According  to  Bennett  (475),  there  are  tliree  painful  reactions 
to  pressure.  In  the  first,  the  pain  is  increased  by  pressure  of  any 
kind.  The  lightest  touch  causes  the  most  severe  distress.  Infec- 
tious diseases  of  the  nature  of  influenza  produce  this  condition. 
In  the  second,  the  pain  is  increased  by  deep  pressure  only.  It 
generally  indicates  some  deep  inflammatory  lesion  which  is  not 
disturbed  by  the  superficial  pressure,  but  is  aggravated  by  deep 
pressure.  For  instance,  in  phlebitis,  slight  pressure  over  the  most 
painful  part  is  not  resented,  but  deep   pressure  produces  pain. 


72  PERCEPTION    OF   PAIN    SENSATION 

In  the  third  reaction,  pain  is  increased  by  superficial  pressure. 
In  this  condition,  Bennett  believes  that  a  vasoneurosis  is  present 
and  causes  a  dilatation  and  engorgement  of  the  vessels,  especially 
marked  in  the  muscles ;  the  pain  is  severe  and  is  relieved  by  pres- 
sure and  massage.  On  the  contrary,  if  the  engorgement  is  in- 
flammatory, and  an  exudate  is  present,  the  pain  will  be  increased 
rather  than  decreased  on  pressure. 

Tenderness  may  be  present  over  the  area  in  which  pain  is 
complained  of,  but  which  is  not  the  area  of  the  lesion,  or  it  may 
be  entirely  absent  over  that  area  and  be  found  at  some  distant 
point.  A  few  cases  of  disease  in  which  the  tenderness  and  its  re- 
lation to  the  location  of  pain  differ  are  given  below  (Bennett)  : 

Disease  Location  of  Pain       Location  of  Ten- 

derness 

Tabes  dorsalis.              Epigastrium   (com-  Over  the  spinal  verte- 

monly) .  bra. 

Sciatica.                          Often  back  of  thigh  Over  the  great  sciatic 

and  knee.  notch. 

Intercostal  neuralgia.  In  epigastrium  or  in  Over  the   intercostal 

the  middle  line  of  spaces, 
the  body. 

Gastric  ulcer.                Opposite  the  eighth  oi  Over  the  gastric  re- 
tenth    dorsal    ver-  gion. 
tebra. 

Gall-bladder  disease.    In  the  back  at  the  an-  Over  the  gall-bladder 

gle  of  the  scapula.  region. 

Rigidity  of  the  underlying  muscles  is,  as  a  rule,  associated 
with  tenderness.  This  is  a  good  confirmative  sign  that  pain  is 
present  (of  some  diagnostic  value  in  malingering).  Points  which 
aid  in  differentiating  the  malingerer  from  the  actual  sufferer  are 
the  changes  in  respiration  and  pulse,  both  in  the  rate  and  rhythm, 
when  pain  is  produced.  These  are  not  absolute,  because  in  some 
cases  where  there  is  actual  physical  objective  tenderness  no  change 
in  the  pulse  or  respiration  is  noticed  in  making  pressure  upon  the 


PARESTHESIA  73 

tender  point  or  points.  Changes  in  the  pupil,  however  generally 
they  occur,  should  also  always  be  sought,  for  pain  causes  dilatation. 
Paresthesia. — This  is  a  term  used  to  describe  a  group  of  symp- 
toms simulating  pain,  yet  not  of  sufficient  intensity  to  be  so 
classified.  Under  it  are  grouped  such  feelings  as  numbness,  prick- 
ing, and  tickling.  They  are  probably  due  to  a  lesser  degree  of 
irritation  than  that  which  produces  pain.  For  instance,  pres- 
sure upon  the  ulnar  nerve  at  the  elbow  will  produce  tingling  and 
numbness,  while  a  sharp  blow  will  produce  actual  pain.  Like- 
wise, it  is  common  when  one  knee  is  crossed  over  the  other  to 
have  the  foot  of  the  crossed  leg  go  to  sleep  from  pressure  on  the 
sciatic  nerve.  A  fractured  lower  end  of  the  humerus  may  also 
press  upon  the  ulnar  nerve  and  cause  paresthesia  in  the  ulnar 
distribution. 


CHAPTER  V 

CLASSIFICATION  OF   PAIN 

Several  different  classifications  of  pain  might  be  made,  but 
the  one  most  generally  used  is  that  which  classifies  them  accord- 
ing to  origin,  namely,  subjective  and  objective  (first  used  by  Henle). 

SUBJECTIVE    PAINS 

Subjective  pains  are  those  which  have  no  physical  cause  for 
existence,  but  are  a  product  of  mental  action  arising  from  some 
changes  of  the  coordinating  centers  of  the  sensorium. 

There  are  a  variety  of  conditions  in  which  subjective  paiuo 
play  a  great  role.  The  most  frequent  of  these  are  emotional  states, 
hysteria,  habitual  reactions,  depressions  of  various  types,  com- 
pulsion neuroses,  etc.  In  hysteria,  wherein,  owing  to  intense 
mental  concentration  on  the  subject  of  pain,  with  the  fixed  idea 
that  it  can  be  and  is  present  in  a  certain  place  (ovaries,  for  in- 
stance), it  happens  that,  subjective  to  the  patient,  to  all  intents 
and  purposes,  pain  is  present  in  such  an  area  or  point.  Hysterics 
are  noted  for  the  rapid  changes  in  the  location  of  their  pains; 
for  the  great  variety  of  pains  with  which  they  are  afflicted,  and 
their  sudden  change  from  those  of  mild  character  to  those  of 
great  severity.  These  pains  may  have  no  organic  basis  for 
their  presence,  but  may  be  the  product  of  deranged  mentality, 
the  result  of  disordered  mental  equilibrium  wherein  impulse  is 
misinterpreted,  and  the  stimulus  which  ordinarily  would  be  rec- 
ognized as  only  a  slight  irritation  is  magnified,  enlarged,  and 
changed  in  its  journey  to  the  sensorium,  so  that  it  is  felt  by  the 
centers  as  pain ;  or  else  the  centers  themselves  are  diseased,  so 
that  they  interpret  normal,  non-painful  phenomena  as  painful. 
74 


SUBJECTIVE   PAINS  75 

It  is  manifest  that  these  ideas  of  pain,  or  the  subjective  impres- 
sion of  pain,  are  the  resnlt  of  impressions  stored  up  in  the  mem- 
ory centers,  which  are  recalled  when  the  proper  associations  are 
aroused.  These  recalled  sensations  may  he  either  autosuggestive 
or  heterosuggestive. 

In  autosuggestive  sensations  the  suggestive  stimulus  arising 
in  the  organism  itself  is  due  to  some  pathological  change,  while 
in  the  heterosuggestive  sensations  the  stimulus  arises  outside  the 
organism,  as  in  hypnosis,  wherein  pain  can  be  felt  in  response  to 
a  suggestion  made  by  the  hypnotizer.  Subjectively-excited  pain 
can  be  made  to  appear  and  disappear  at  the  will  of  the  operator. 
Also,  sensations  which  normally  are  pleasant  may,  by  the  sugges- 
tion of  the  operator,  be  interpreted  as  painful,  thus  showing  how 
a  functional  misinterpretation  may  occur  without  any  organic 
basis.  These  suggested  pains  often  are  localized  in  a  particular 
organ,  as  in  the  hip  joint  in  cases  of  so-called  hysterical  hip-joint 
disease.  Here  the  area  corresponds  to  the  terminal  distribution 
areas  of  several  nerves,  and  is  not  localized  to  the  area  supplied  by 
the  terminal  filaments  of  a  single  nerve.  The  projected  idea  of 
pain  comes  from  the  intellectual  coordinating  center  acting  in  con- 
junction with  the  memory  center.  In  this  respect,  the  question  has 
often  been  asked,  can  we  conjure  up  in  our  dreams  the  sensation 
and  impression  of  pain  ?  From  recollection  of  my  owti  dreams,  I 
am  incapable  of  answering  in  the  aiRrmative ;  but  several  of  my 
patients  have  informed  me  that  they  have  dreamed  of  being  in 
severe  pain,  which  proved  to  be  a  myth  upon  awaking,  there  being 
present  no  perceptive  irritation  which  might  act  as  a  subconscious 
cause  of  the  pain.  This  dream-pain  has  been  described  as  similar 
to  the  sudden  acute  and  agonizing  pain  associated  with  the  cut 
of  a  dagger,  or  contact  with  fire,  and  the  sensation  is  as  real  as 
though  actually  occurring.  In  these  cases,  it  seems  as  though  all 
the  tracts  from  the  reception  center  to  the  memory  center  are 
blocked,  except  those  for  touch  and  pain,  and  from  the  memory  to 
the  ideational  center  all  the  tracts  except  those  for  pain  are  blocked. 
Therefore,  the  ideational  center  perceives  only  impressions  which 
by  the  memory  center  are  interpreted  as  painful. 


76  CLASSIFICATION   OF   PAIN 

Emotional  Pains. — The  emotional  pains  are  those  which  are 
the  result  of  excessive  emotion  of  anv  kind.  They  are  felt  in 
great  anger,  great  sorrow  or  distress,  and  kindred  feelings.  The 
sensation  experienced  is  not  in  reality  a  pain,  but  rather  a  feeling 
of  unpleasantness.  That  it  is  an  actuality  may  be  deduced  from 
the  fact  that,  upon  its  disappearance,  the  body  is  left  in  the 
greatest  fatigue.  Another  and  a  related  sensation  is  the  sense  of 
depression  felt  in  cardiac  disease  (angina  pectoris).  This  in- 
creases to  anxiety,  then  progresses  through  the  stage  of  distress 
until  the  actual  pain  is  apparent. 

Hysteria. — Hysteria  probably  includes  the  largest  number  of 
subjective  pains.  It  is  only  recently  that  hysteria  has  been  recog- 
nized as  an  entity,  and  as  a  disease  worthy  of  the  most  pains- 
taking attention.  Heretofore,  when  a  patient  complained  of  pain, 
and  no  objective  lesion  was  found,  he  was  dismissed  with  the  diag- 
nosis of  hysteria ;  but  this  did  not  always  prevent  death  from  the 
disease  with  which  he  was  suffering.  The  absence  of  a  pain  in  a 
complex  of  symptoms  where  ordinarily  it  would  be  may  also 
lead  to  a  wrong  diagnosis  of  hysteria.  Roch  mentions  the  case 
of  a  patient  who  had  stercoraceous  vomiting,  without  the  presence 
of  pain  and  tympany,  and  who  was  permitted  to  die  without 
operation  because  of  the  diagnosis  of  hysteria.  This  case  illus- 
trates how,  because  of  the  absence  of  pain,  hysteria  might  be 
diagnosed.  The  same  would  apply  just  as  well  if  pain  had  been 
present  and  the  other  symptoms  absent.  That  some  change  which 
accounts  for  the  pain  is  present  in  hysteria  caunot  be  doubted; 
and  that  the  pains  of  hysteria  are  imaginary  and  have  no  basis  is 
ridiculous.  As  remarked  by  W.  H.  Thompson,  how  is  it  possible 
for  a  patient,  through  imaginary  means,  to  cause  a  paralysis 
of  one  vocal  cord,  when  perhaps  she  does  not  even  know  that  she 
has  such  an  apparatus,  or  that  it  is  connected  with  the  formation 
of  the  voice  ? 

Explanation  of  Hysterical  States. — It  may  be  of  some  service 
to  glance  over  rapidly  some  of  the  suggestions  made  by  various 
authors  as  to  the  possible  explanation  for  these  states.  Clevenger 
(40,  p.  195),  for  instance,  believes  that  the  anesthesia  of  hysteria 


SUBJECTIVE   PAINS  77 

is  due  to  deficient  nutrition  from  improper  vascularization,  the 
result  of  localized  anemia  from  constriction  of  the  vessels.  This 
anesthesia  is  followed  by  a  return  of  sensation,  and  in  some  cases 
by  hyperesthesia  or  even  by  hyperalgesia,  upon  the  resumption  of 
the  blood  supply  to  the  part  with  a  consequent  engorgement  of  the 
vessels.  The  action  of  suggestion  in  relieving  pain  can  be  ex- 
plained by  the  lessening  of  the  blood  supply  to  the  affected  part. 

Sharkey  (456)  points  out,  as  an  argument  in  favor  of  the 
central  origin  for  anesthesia  in  hysteria,  that  when  anesthesia  is 
due  to  an  organic  disease  the  patient  is  aware  of  his  loss,  but  that 
when  it  is  due  to  hysteria  he  is  unaware  of  it.  This,  according  to 
Sharkey,  shows  that  in  the  first  case  the  psychical  centers  are  in- 
tact, and  that  in  the  second  case  they  must  be  involved  so  that  the 
patient  cannot  feel  pain,  and  at  the  same  time  is  unaware  of  his 
loss.^ 

However,  the  most  likely  cause  of  hysteria  is  some  disturbance 
of  brain  metabolism  due  to  vasomotor  changes.  In  some  cases 
there  is  a  transference  of  the  hemianesthesia  or  hyperesthesia 
from  one  side  of  the  body  to  the  other.  ''In  these  subjects,  the 
feeling  on  the  affected  side  is  restored  when  small  metallic  plates 
or  compresses  are  applied  to  the  skin.  At  the  same  time  that 
the  affected  part  recovers  its  sensibility  the  corresponding  part  of 
the  opposite,  healthy  side  or  limb  becomes  affected.  It  was 
thought  that  the  application  of  the  plates  produced  a  galvanic 
current  and  that  this  was  instrumental  in  causing  the  transfer- 
ence ;  but  it  is  now  believed  that  it  is  due  to  the  same  thing  which 
causes  the  application  of  cold  plates  to  one  side  of  a  healthy  per- 

'■  The  cause  of  this  loss  may  be  due  to  the  fact  that  the  nerve  cells  seem 
to  contain  a  substance  of  the  nature  of  neurin,  which  can  be  transferred  from 
one  cell  to  another,  in  case  of  exhaustion  of  one  set  of  cells  from  hyperactivity. 
Should  the  cells  be  unable  to  replenish  their  supply  of  this  activating  substance, 
they  are  unable  to  appreciate  impulses,  and  anesthesia  results.  Should  the  acti- 
vating material  be  in  excess,  the  cells  become  irritated  and  respond  to  less  than 
normal  stimuli,  giving  rise  to  hyperesthesia  and  hyperalgesia.  In  some  cases 
there  are  small  areas  of  anesthesia  or  hyperesthesia  over  the  body.  These  are 
explained  by  Sharkey  by  the  fact  that  after  the  sensory  fibers  leave  the  inter- 
nal capsule  they  separate  and  are  distributed  to  widely-separated  areas  of  the 
cortex,  so  that  it  would  be  possible  for  some  of  these  areas  to  be  affected,  and 
thus  give  rise  to  areas  of  changed  sensibility. 


78 


CLASSIFICATION    OF   PAIN 


son  to  increase   the  sensibility  of  the   opposite  side"    (Landois, 
"Physiology,"  p.  936,  American  translation,  1904). 

Distribution  of  Hysterical  Pain. — The  area  of  distribution  of 
analgesia  in,  a  hysterical  subject  may  follow  the  distribution  of 


Fig.  29. — Areas  of  Analgesia  in  Hysteria. 
A  is  a  case  of  the  cerebrospinal  type.  B  is  a  case  of  a  pure  cerebral  type. 
In  A  all  superficial  reflexes  to  painful  stimuli  and  to  hot  and  cold  sensa- 
tion were  lost  over  the  shaded  areas.  Loss  of  sensation  to  touch  was 
less  extensive.  In  B  the  shaded  areas  indicate  the  loss  of  sensation  to 
touch,  pain,  heat  and  cold.     (From  Head,  Brain,  Vol.  XVI,  p.  116.) 


the  cord  zones,  or  of  the  cerebrospinal  areas.  The  cerebrospinal 
areas  generally  have  .  sharp  boundaries,  and  have  a  transverse 
delimitation,  as  shown  in  the  accompanying  figures  (Fig.  29,  A 
and  B),  which  are  taken  from  Head.  These  states  are  inde- 
pendent of  any  nerve  or  nerve  lesion,  even  section.  They  are  not 
influenced  by  inflammation.  Frequently  these  pains  make  their 
first  appearance  after  the  examination  of  the  physician,  who,  too 
often,  by  the  care  with  which  he  goes  over  an  area,  and  his  oft- 
repeated  query  as  to  the  presence  of  sensory  changes,  rather  sug- 


SUBJECTIVE   PAINS  '     79 

gests  the  pain  to  the  patient.  Hysterical  pain  is  also  frequently 
induced  by  emotional  shock.  Cold,  heat,  pressure,  and  irritation, 
as  a  rule,  have  no  effect  upon  it.  Pressure  points — that  is,  areas 
which  are  particularly  joainful  to  pressure — are  frequently  found 
in  hysteria.  According  to  Dercum  (150,  p.  849),  the  most  fre- 
quent hysterical  areas  are:  (1)  the  inguinal  region  (women),  (2) 
the  inframammary  region,  (3)  above  the  spines  of  the  scapula, 
(4)  to  the  sides  of  the  dorsal,  cervical  and  lumbar  vertebra,  (5) 
over  the  sacrum,  and  (6)  over  the  coccyx. 

Diagnosis  of  Hysterical  Pain. — In  the  diagnosis  of  such  a  con- 
dition, the  limitations  of  the  fields  of  vision  and  the  loss  of  the 
pharyngeal  reflex  are  of  considerable  weight.  Diller  (557)  classi- 
fies the  evidence  as  negative  and  positive.  Under  the  negative 
evidence,  he  cites  the  facts  that  the  pain  does  not  conform  to  any 
one  organic  disease,  and  that  it  is  very  contradictory  in  its  charac- 
ter, time,  appearance,  and  duration.  Under  the  positive  evidence 
is  the  fact  that  suggestion  often  relieves  pain.  The  patient  gener- 
ally is  very  detailed  in  his  description  of  the  location,  time  of 
appear^ance,  type,  and  intensity  of  the  pain.  The  sufferer  from 
real  pain,  on  the  contrary,  makes  but  few  remarks  concerning  his 
pain,  and  when  he  does  so  they  are  generally  brief  and  to  the  point 
(Thompson).  Hysterical  pains  are  not,  as  a  rule,  relieved  by 
drugs,  such  as  morphin,  while  organic  lesions  are  so  relieved. 

While  in  many  cases  a  patient  may  seem  to  be  complaining 
of  a  pain  in  order  that  he  may  arouse  the  sympathy  of  those  inter- 
ested, we,  as  examining  physicians,  should  not  conclude  because 
we  are  unable  to  find  an  organic  basis  for  the  pain  that  it  does 
not  exist.  The  diagnosis  of  hysterical  pain  is  often  but  a  cloak 
under  which  the  physician  hides  his  ignorance.  When  we  con- 
sider that  the  nervous  system  is  of  considerable  volume  and 
weighs  about  six  pounds,  and  that  it  is  subject  to  the  same  varia- 
tions of  nutrition  and  change  as  are  the  other  tissues  of  the  body, 
it  is  easy  to  appreciate  how  it  may  be  subject  to  the  vicissitudes 
of  the  other  tissues,  and  therefore  subject  to  irritation  and  fatigue, 
the  same  as  are  these  tissues.  In  children,  hysterical  pain  is  very 
rare,  because  they  are  too  young  to  have  experienced  much  pain, 


80  CLASSIFICATION    OF    PAIN 

and  hence  are  free  from  pain  memories,  and,  as  a  consequence, 
are  also  free  from  hysterical  pain. 

Hypnosis. — Hypnosis  is  sometimes  capable  of  bringing  into  con- 
sciousness the  storcd-np  pain  experience  of  the  subject.  It  causes 
those  dim  and  forgotten  sensations  which  have  been  present  in 
the  past  to  dawn  into  consciousness.  It  is  only  the  drawing  away 
of  the  veil  from  the  subconscious  state  and  the  forcing  of  it  into 
view.  The  hypnotizer  can  suggest  the  idea  of  pain  to  the  hypno- 
tized, and  can  make  him  feel  pain  in  every  act  and  every  move- 
ment. He  reproduces,  as  it  were,  the  states  which  are  present  in 
hysteria. 

Habit  Pains. — A  condition  closely  related  to  the  foregoing  is 
that  of  the  so-called  habit  pains.  This  is  the  name  given  to  that 
great  class  in  which  the  pathways  for  pain  have  been  so  grooved 
from  frequent  repetition  that  on  the  least  provocation  the  stimulus 
travels  over  them  and  gives  rise  to  pain  sensation.  These  fre- 
quently follow  a  trauma  which  has  occurred  some  time  previously. 
Such  a  trauma  may  cause  abnormal  or  unusual  susceptibility  to 
pain  production,  and  what  otherwise  would  be  felt  as  a  non- 
painful  stimulus  gives  rise  to  pain.  Habit-pains  frequently  per- 
sist after  operations  of  various  kinds  which  have  been  undertaken 
because  of  the  pain,  and  continue  in  spite  of  the  fact  that  all  the 
abnormalities  have  been  corrected.  The  persistence  can  only  be 
accounted  for  upon  the  habit-pain  hypothesis.  The  pain  is  par- 
ticularly apt  to  persist  when  opiates,  such  as  morphin,  have  been 
given  before  the  operation. 

Monomania  Pains. — Brissaud  (Progres  Med.,  XIX,  No.  2) 
mentions  another  variety  of  habit-pain,  in  which  the  pain  recurs 
as  a  habit  at  a  certain  time,  or  in  connection  with  certain  objects. 
Brissaud  believes  that  patients  subject  to  such  pain  are  suffering 
from  an  obsession,  and  that  they  have  a  delusion  of  pain  when  none 
is  present.  The  pain  resembles  that  due  to  occupation  neuroses, 
and  represents  a  variety  of  pain  caused  by  overactivity  of  a  certain 
neuromuscular  apparatus,  and  nature's  attempt  to  hinder  excessive 
action. 

Occupation  Neuroses. — Dr,  Walton  ("International  Clinics," 


SUBJECTIVE   PAINS  81 

Vol.  IV,  p.  261,  17th  series)  recites  several  cases  in  which,  in- 
stead of  the  muscular  spasm  (found  in  certain  neuroses,  such  as 
writer's  cramp),  severe  pain  is  felt,  not  localized  to  the  distribu- 
tion area  of  any  nerve,  but  rather  extending  over  the  area  of  the 
muscle  and  its  insertion.  This  pain  is  induced  only  by  making 
the  occupation  movements,  and  is  not  invariably  produced  even 
then.  If  the  occupation  is  continued,  every  repetition  of  the  act 
causes  pain.  By  this  time,  the  pain  is  produced  by  other  move- 
ments than  those  of  the  occupation,  and  finally  spontaneous  and 
paroxysmal  pain  is  apt  to  appear  in  the  same  region,  not  generally 
following  the  exact  tract  of  any  nerve,  but  rather  distributed  over 
the  area  involved  in  the  muscular  action,  and  perhaps  radiating 
therefrom.     Tenderness  may  or  may  not  be  present.     Examples: 

(1)  Physician,  laryngologist ;  pain  in  the  side  of  the  neck 

and  back  of  the  ear ;  comes  on  when  the  head  is  placed 
in  the  position  for  operating;  relieved  and  finally 
cured  by  rest. 

(2)  Golf  player;  pain  in  the  arm  in  the  region  of  inser- 

tion of  the  deltoid,  produced  at  each  swing  of  the 
club. 

(3)  Pain  in  arm;  persistent  with  paresthesia ;  due  to  sewing. 

(4)  Music  teacher   (piano);  pain  in  right  arm;  numbness 

and  easy  tiring  of  the  fingers ;  relieved  on  stopping  the 
piano-playing. 

(5)  Pain  in  the  entire  forearm;  due  to  overwork  of  the  arm; 

moderate  tenderness  over  the  entire  forearm  present. 

(6)  Ticket  agent;  pain  and  tenderness  on  the  radial  side  of 

the  first  phalanx  of  the  ring  finger  of  the  right  hand, 
due  to  pressure  made  by  the  corners  of  the  tickets 
against  the  spot  in  stamping. 

As  is  remarked  in  an  editorial  in  the  Journal  of  the  American 
Medical  Association  (LVI,  12,  898),  all  of  the  occupation  pains 
may  be  avoided  by  proper  precautions — and  as  examples  are  given 
the  cure  of  the  pains  in  the  bricklayer's  back  by  placing  the  bricks 
on  a  proper  platform  easy  to  be  reached,  or  of  the  hammerer  who 


82  CLASSIFICATION   OF   PAIN 

is  relieved  of  the  pains  in  his  arm  by  using  the  opposite  arm  in 
his  work. 

OBJECTIVE    PAIN 

By  objective  pain  is  meant  that  pain  which  is  excited  by  some 
cause  or  agent  foreign  or  abnormal  to  the  area  in  or  near  which 
it  is  excited.  Such  a  pain  may  be  produced:  (1)  in  the  centers, 
as  the  brain  or  cord,  and  (2)  in  the  nerves,  as  the  trunk  or  its 
terminations.  It  always  is  the  result  of  some  demonstrable  patho- 
logical change. 

CENTEAL    OBJECTIVE    PAIN 

The  cortical  brain  tissues  contain  no  known  pain-receptors. 
Pains  in  the  head,  about  the  head,  etc.,  are  due  to  peripheral  action 
usually  upon  the  receptors  of  the  trigeminus,  widely  distrib- 
uted in  the  meninges  covering  the  cerebrum.  The  pain  of 
pressure  within  the  head,  as  in  hydrocephalus,  brain  tumor, 
lead  encephalopathies,  etc.,  is  probably  also  carried  through  the 
trigeminus. 

Purely  cortical  lesions  are  not  known  to  produce  pain,  nor  are 
they  known  to  bring  about  any  increase  or  decrease  of  sensibility 
to  measured  painful  stimuli.  Only  in  the  case  of  recent  lesions, 
or  in  those  accompanied  by  epileptiform  seizures,  has  there  been 
found  to  be  any  reduction  in  pain  sensibility.  The  cortex  as  a 
place  of  origin  for  central  pains  may  be  excluded.  The  role  of  the 
cortex  in  the  analysis  of  other  forms  of  sensibility  does  not  lie 
within  the  province  of  this  chapter. 

Central  pains,  however,  may  be  present  and  due  to  lesions 
in  the  optic  thalamus,  which  is  the  chief  sensory  organ  of  the 
brain;  the  major  relay  station. 

Two  features  stand  out  in  thalamic  lesions  so  far  as  sensations 
are  concerned.  One  consists  in  the  excessive  response  to  affective 
stimuli.  There  is,  as  Head  and  Holmes  express  it,  an  "overload- 
ing of  the  feeling  tone."  It  has  been  present  in  the  thalamic 
syndrome  cases  reported  by  Roussy  and  others  (Jelliffe,  "Tha- 
lamic Syndrome,"  N.  Y.  Med.  Jour.,  1910).,  This  excessive  re- 
sponse— explosive  laughter,   explosive   crying — bears   no  relation 


OBJECTIVE   PAIN  83 

to  the  quantity  of  painful  stimuli.  It  is  an  interesting  feature 
that  such  variations  in  effective  response  may  be  unilateral. 

Thalamic  pains  are  usually  very  severe  and  intractable.  They 
are  not  infrequently  seen  in  hemiplegics  who  also  suffer  from 
thalamic  lesions.  Lesions  of  the  thalamus  seem  to  permit  all 
sensory  stimuli  to  be  felt  as  painful.  Most  of  the  reported  tha- 
lamic pains  have  been  located  in  the  ujDper  extremities. 

Lesions  about  the  cord,  meningeal  exudates,  pressures,  tabes, 
tumor,  give  rise  to  pain.  Such  are,  for  the  most  part,  due  to 
action  upon  the  peripheral  sensory  neuron.  They  are  not,  prop- 
erly speaking,  intracordal  lesions,  and  do  not,  as  a  rule,  give  rise 
to  local  pain.  Pain  tracts  may  be  cut  off,  as  in  syringomyelia, 
hematomyelia,  intracordal  tumors,  etc.,  but  do  not  give  rise  to  pain. 
They  cause  hyperesthesia,  and  may  lower  the  threshold  to  painful 
stimuli,  but  apparently  do  not  cause  spontaneous  pain. 

PERIPHEEAL  OBJECTIVE   PAINS 

Peripheral  pains  are  those  which  are  due  to  action  on  the  axis 
cylinder,  the  ganglia  cells  or  the  receptors,  and  are  objective  in 
that  some  definite  lesion  (as  a  rule)  acts  as  the  producing  factor. 
They  may  be  classified  as  to  cause,  manner  of  propagation,  time, 
constancy,  and  character. 

Causes.- — The  causes  of  peripheral  objective  pain  may  be  di- 
vided into  organic  and  functional.  The  organic  causes  are  those 
which  are  due  to  changes  in  structure,  or  in  tlie  relationship  of 
different  anatomical  elements  to  each  other.  They  may  in  turn 
be  divided  into  intrinsic  and  extrinsic.  The  intrinsic  causes  give 
rise  to  parenchymatous  pains,  and  include  inflammation,  new 
growths,  muscular  contraction,  or  displacement  of  parts,  as  in 
those  cases  where  teeth  have  not  erupted  and  are  still  in  the 
maxilla,  and  where,  by  pressure  upon  the  adjacent  structures, 
they  cause  great  pain.  The  extrinsic  causes  include  all  lesions 
making  pressure  upon  the  nerves  or  nerve  terminals,  as  displace- 
ment and  pressure  by  adjacent  organs,  new  growths,  etc.,  and 
stretching  of  the  nerves,  ligaments,  or  other  attachments,  in  dis- 
placement, or  in  new  growths  of  different  organs. 


84  CLASSIFICATION    OF   PAIN 

The  functional  pains  are  di;e  to  excessive  activity  of  an  organ 
(generally  the  activity  is  transitory),  as  in  the  stomach  (pyloric 
obstruction)  ;  in  the  intestines  (obstruction)  ;  in  the  testicles  (hy- 
persexual  activity)  ;  and  in  the  brain   (excessive  mental  work). 

Pakexchymatous  Pain. — Parenchymatous  pain  is  due  to 
some  pathological  condition  that  involves  the  sensory  nerve  termi- 
nations. It  may  be  due  to  local  irritation,  such  as  occurs  (1)  in 
inflammation,  (2)  in  torsion  or  stretching  of  the  fibers  by  muscu- 
lar contraction,  (3)  in  thermic  irritation,  as  in  burns,  and  (4) 
in  chemical  changes  due  to  acids. 

(1)  Inflammatory  Pain. — An  organ  consists  of:  (1)  the 
essential  structure,  such  as  cells;  (2)  the  supporting  structure, 
consisting  of  connective  tissues,  in  which  are  found  (a)  lymph 
channels,  (b)  blood  vessels  (arteries,  capillaries,  and  veins),  and 
(c)  nerves  (sympathetic  and  cerebrospinal)  ;  (3)  the  encapsulat- 
ing structures  (capsules)  ;  and  (4)  the  adjacent  structures  (lymph 
glands,  nerve  plexuses).  Therefore,  when  the  pain  is  parenchy- 
matous, it  must  occur  in  one  or  more  of  the  structures  enumerated 
above. 

In  inflammation  we  know  that  the  first  sign  of  the  beginning 
process  is  in  the  blood  vessels,  which  dilate  and  thus  bring  an 
additional  supply  of  blood  to  the  part.  It  is,  no  doubt,  the  vast 
increase  in  the  blood  supply  and  the  greatly  increased  force  of 
the  systolic  impulse  in  the  diseased  area  that  cause  the  throbbing 
pain,  recognized  as  the  early  stage  of  an  active,  inflammatory 
process.  It  is,  however,  very  difficult  to  say  exactly  through  what 
channels  or  means  the  knowledge  of  this  increased  blood  supply  is 
conveyed  to  the  sensorium.  It  may  be  conveyed  by  the  following 
means:  (1)  nerve  fibers  distributed  to  the  vessel  walls  which  are 
associated  with  the  vasomotor  nerves;  (2)  nerve  fibers  distributed 
to  the  cellular  substance;  and  (3)  nerve  fibers  distributed  to  the 
capsules  of  the  gland. 

We  know  that  the  lumina  of  the  vessels  in  inflamed  areas  are  in- 
creased much  beyond  their  normal  size,  so  that  the  combined  area  of 
the  lumina  of  the  vessels  within  the  inflamed  area  is  several  times 
the  area  of  the  lumina  of  the  vessels  entering  the  part;  and  the 


OBJECTIVE   PAIN  85 

systolic  pressure  is  as  much  greater  in  the  part  as  the  area  of  the 
vessels  in  the  part  is  greater  than  the  area  of  the  vessels  entering 
it.  This  is  according  to  a  well-known  principle  of  mechanics.  To 
be  more  definite,  we  may  assume  the  area  of  the  lumina  of  the 
entering  vessels  to  be  one  square  foot,  and  the  area  of  the  lumina 
of  the  contained  vessels  to  be  twenty  square  feet.  The  pressure 
on  every  square  foot  of  the  enlarged  area  is  the  same  as  that  on 
the  small  area.  Therefore,  it  will  be  twenty  times  the  smaller 
pressure  (for  example,  if  the  smaller  is  one  pound,  the  larger  will 
be  twenty  pounds).  Thus,  it  is  easy  to  understand  how  the  in- 
creased area  of  the  vessels  will  indirectly  cause  the  sensation  of 


Vessel  entering  part 


Area  thirty  times  that  of 

small   vessel    entering 
the  part 


Area  o{  vessels  in  inflamed  part 


Fig.  30. — Method  of  Pain  Production  in  Inflammation. 

throbbing.  It  would,  further,  cause  compression  of  any  nerve 
fibers  which  are  found  in  the  organ,  and  would  also  undoubtedly 
exert  a  great  pressure  upon  the  capsule.  Both  of  the  factors  would 
produce  pain. 

The  cause  of  the  throbbing  in  severe  inflammation  may  be 
the  impulse  of  the  blood  in  the  dilated  vascular  paths  in  the 
inflamed  area,  or  the  result  of  a  nervous  vasomotor  reflex,  caus- 
ing an  alternating  dilatation  and  contraction  of  the  vessel  walls. 
Personally,  I  am  inclined  to  the  belief '  that  it  is  due  to  the 
propulsion  of  the  blood  into  the  part  without  any  means  of  re- 
turn, the  capillary  paths  being  blocked,  and  permitting  but  slight 
venous  return  from  the  inflamed  area,  or  that  the  return  is  so 
slow  that  the  blood  accumulates  in  the  part.  As  a  consequence, 
the  force  exerted  through  the  small  vessels  entering  the  area 
acts  as  in  a  hydraulic  foree-pump,  and  the  pressure  and  force 
are  increased  in  the  much  larger  area  which  the  vessels  supply. 
Thus,  this  magnified  force  is  seen  by  the  alternate  pallor  and 


86  CLASSIFICATION    OF   PAIN 

flushing  of  the  part.  The  nerves  in  the  part  are  stimulated  by 
the  dilatation  of  the  vessels  in  the  area  adjacent  to  the  inflamma- 
tion, and  impulses  are  sent  to  the  cord,  which  sends  them  back 
again  as  reflexes,  which  act  as  vasomotor  dilators.  Thus,  there  is 
dilatation  at  each  systole  and  a  consequent  contraction  at  each 
diastole. 

In  the  later  stages  of  inflammation  the  throbbing  pain  which 
was  originally  present  is  changed  to  a  dull  ache.  This  is  due  to 
the  fact  that,  at  this  time,  the  vessel  walls  and  the  capsule  are 
dilated  to  their  fullest  extent,  and  will  not  admit  any  more  blood ; 
and,  instead  of  the  intermittent,  systolic  pressure  that  is  found  in 
the  early  stages,  there  is  present  a  pressure  that  is  constant  and 
unvarying.  Again,  as  the  inflammation  begins  to  subside  (pro- 
vided the  extra vasated  blood  does  not  block  the  channels)  the 
former  throbbing  pain  may  recur. 

Sometimes  it  is  found  that  the  inflammatory  reaction  is  not 
limited  to  the  confines  of  the  organ  in  which  it  is  found,  but  ex- 
tends beyond  these  limits  and  progresses  in  the  course  of  the 
adjacent  lymph  paths,  finally  reaching  some  *of  the  neighboring 
lymph  glands,  where  the  inflammatory  process  becomes  active, 
thus  producing  further  pain. 

In  some  cases  parenchymatous  pain  radiates  in  various  direc- 
tions from  its  place  of  origin ;  this  radiation  may  be  explained 
upon  one  hypothesis:  that  the  painful  impulses  are  conveyed 
from  the  organ  to  an  adjacent  nerve  plexus  where  they  be- 
come diffused.  From  the  plexus  the  impulses  are  carried  to 
the  brain,  and  give  rise  to  the  impression  that  the  pain  arises 
in  the  entire  area  to  which  the  nerves  forming  the  plexus  are  dis- 
tributed. 

Parenchymatous  pain,  due  to  inflammation  of  viscera,  seems 
to  be  more  of  a  myth  than  an  actuality,  for,  since  it  is  a  fact 
that  no  sensory  nerves  are  distributed  to  the  parenchyma  of  vis- 
cera, it  is  difiicult  to  understand  how,  in  the  organ  itself,  painful 
sensations  can  be  present.  The  following  are  instances  (Mc- 
Kenzie)  illustrating  the  absence  of  pain  in  diseases  of  certain 
viscera : 


OBJECTIVE   PAIN  87 

(1)  Kidney  inflammation,  especially  the  chronic  variety,  is 
entirely  painless. 

(2)  Disease  (inflammatory)  of  the  liver  is  without  pain,  as 
a  rule,  and  the  pain  which  is  present  in  hepatitis  is  ofteil  due 
either  to  involvement  of  the  capsule  or  to  the  tractions  made  upon 
the  abdominal  wall  by  the  pull  of  adhesions  passing  between 
the  liver  and  its  parietes.  The  only  exception  is  hepatitis  syphi- 
litica (ISTeusser). 

(3)  Lung  tissue  lacks  pain-sensation,  and  in  disease  such  as 
pneumonia  the  patient  is  entirely  unaware  of  the  baneful  changes 
occurring  in  the  lung  until  the  pleura  becomes  involved  and  pain^ 
is  produced. 

(4)  The  testicle  is  also  without  pain-sensation.  Yet  orchitis 
is  a  condition  which  is  very  painful ;  but  it  seems  that  the  painful 
reaction  in  this  disease  is  due  to  an  extension  of  the  inflamma- 
tory process  to  the  adjacent  structures  (epididymis). 

(5)  The  heart  is  also  without  a  local  pain  reaction.  It  seems 
that  in  painful  cardiac  diseases  the  painful  condition  is  due  to 
an  inflammation  of  the  myocardium  producing  pain  which  is  re- 
ferred to  the  anterior  thoracic  wall. 

Characteristics  of  inflammatory  pain  are:  (1)  the  pain  is 
produced  on  pressure;  (2)  movement  of  the  part  affected  or  of 
any  adjacent  part,  causing  pressure  on  the  inflamed  area,  causes 
pain;  (3)  the  function  of  the  part  (because  of  pain)  is  abolished, 
as  the  rigidity  of  the  hip,  which  occurs  in  hip-joint  disease  (see 
Ryder,  35).  It  has  been  observed  that  inflammatory  pain  is 
more  intense  in  colon-bacillus  and  streptococcic  infection  than  in 
most  other  infections. 

Parencliymatous  ijain  in  glandular  organs,  such  as  the  lymph 
glands,  may  be  due  to  stretching  of  the  capsule  or  to  involvement 
of  the  nerves  which  accompany  the  arteries  into  the  part.  In 
glandular  tissue  there  does  not  seem  to  be  any  parenchymatous 
nerve  supply  other  than  these  filaments  which  accompany  the 
blood  vessels  to  their  ultimate  divisions  in  the  depths  of 
the  tissue.  In  acute  infectious  diseases  the  pain  is  due  to  irrita- 
tion of  the  terminal  nerve  filaments  by  the  toxic  substances  circu- 


88  CLASSIFICATION   OF   PAIN 

lating  in  the  blood.  The  reason  for  the  pain  being  localized  in  a 
particular  area  is  that  in  this  area  the  tissues  are  in  a  state  of 
lessened  resistance  and  any  toxic  change  taking  place  will  be  local- 
ized in  the  less  resistant  region. 

(2)  Traction,  that  is,  stretching  or  pulling  on  the  nerve 
fibers  by  muscular  contraction,  may  cause  pain.  This  is  exempli- 
fied in  the  contractions  of  the  stomach,  intestines,  gall-ducts,  ure- 
ters, and  uterus.  It  seems  that  the  most  severe  pains  felt  by 
patients  are  those  due  to  contraction  of  hollow  viscera,  such  as 
the  intestine  gall-ducts,  ureters,  etc. 

Torsion  of  the  nerve  fibers,  such  as  occurs  in  twisting  of  the 
pedicle  of  an  ovarian  cyst,  also  causes  severe  pain. 

(3  and  4)  Thermic  and  Chemical  Irritations. — Burns,  from 
heat  or  chemical  agents,  cause  pain  by  exposing  the  sensory  ter- 
minal filament  to  irritation  by  external  agents.  Even  exposure 
of  these  filaments  to  the  air  causes  the  most  excruciating  pain. 
The  reason  for  this,  in  all  probability,  is  that,  because  of  their 
sudden  change  from  a  medium  where  temperature  and  surround- 
ings are  equable  to  a  location  where  these  conditions  are  not  favor- 
able, a  great  change  in  their  state  of  irritability  is  produced,  so 
that  they  respond  to  a  greater  degree  than  normal  to  all  stimuli, 
and  especially  so  to  stimuli  to  which  they  had  not  been  previously 
accustomed. 


CHAPTER  YI 

CLASSIFICATION    OF    PAIN  (Continued) 

PERIPHERAL    OBJECTIVE    PAINS 


Propagation  of  Pains. — The  second  part  of  our  classificatiois» 
deals  with  propagated  pains.  These  pains  are  felt  in  areas 
other  than  those  in  which  they  are  produced.  They  may  he 
divided  into  associated,  referred,  projected,  reflex,  and  trans- 
ferred pains. 


Fig.  31. — Varieties  of  Pain:    Origin  and  Transmission. 

89 


90 


CLASSIFICATION    OF   PAIN 


Associated    Pain. — The    associated    pain    depends,    for    its 
production,  upon  the  transference  of  stimuli  from  one  nerve  cell 


Ascending  and  Cnmei  fibre  -  Pain 

i IS  perceived  35  cominqlroirtlhe 

opposite  side  of  the  bodij  and  at 
lower  level. 


Inrermediate  Nf  uron. 
conneclinq  t»vo  sejments 
of  the  cord 


-Transference         Tbi* 
AnLDiv 


Fig.  32.— Scheme  Showing  How  the  Different  Varieties  of  Pain  May 
Arise  and  How  the  Different  Musculosensory  Reflexes  May 
Occur. 


to  another.     In  some  cases  it  is  impossible  to  tell  by  what  means 
the  stimuli  are  transferred,  as  in  the  following  instances: 


H 

Q 
< 

l-H 

o 

o 


O 

M 

P«4 


93 


92  CLASSIFICATION    OF    PAIN 

(1)  A  pain  in  the  top  of  the  head  occurred  with  rectal  fis- 
sures.    Upon  the  curing  of  the  fissures,  the  pain  disappeared. 

(2)  Pain  under  the  heart,  associated  with  labor  pains.  In 
this  case  there  was  also  cutaneous  tenderness,  which  came  and  went 
with  the  labor  pains. 

(3)  Ej)igastric  pain  associated  with  gastritis. 

(4)  Pain  in  knee  in  a  case  of  putrescent  pulp  of  the  lower 
second  bicuspid.  Upon  drawing  the  tooth  the  pain  was  relieved. 
Upon  sealing  it  again,  after  it  had  been  opened  and  drained,  the 
pain  returned.  This  experiment  was  made  several  times  with  like 
results  (P.  V.  McFarland).  This  pain  reference  is  also  present  in 
those  cases  where  two  adjacent  centers  are  involved. 

If  the  original  stimulus  is  very  severe,  and  is  continued  long 
enough,  adjacent  centers  become  irritated,  owing  to  the  central 
stimulation  bv  the  overlapping  or  spilling  of  stimuli  from  the  ad- 
joining centers  to  which  the  stimulus  is  conveyed.  This  is  exem- 
plified in  the  ear  pain  which  follows  toothache,  or  in  the  pain  in 
the  inframaxillary  branch  of  the  fifth  nerve  when  the  stimulus  is 
in  the  superior  maxillary  branch.  In  some  cases  the  pain  be- 
comes very  diffuse,  and  is  felt  over  wade  and  scattered  areas  of  the 
body.     The  diffusion  is  accounted  for  in  two  ways : 

(1)  By  the  crossing  of  the  fibers.  Some  of  the  sensory 
fibers  evidently  pass  over  from  one  side  of  the  cord  to  the  other, 
conveying  impulses  which  stimulate  the  sensory  cells  (in  the  cord) 
supplying  the  opposite  half  of  the  body. 

(2)  By  the  diffusion  of  the  stimuli.  Some  of  the  nerve  cells 
in  the  cord  are  in  close  relationship  with  those  cells  to  which  the 
stimuli  from  the  painful  parts  are  carried.  When  there  is  an  ex- 
cess of  stimulus,  some  passes  over  into  the  neighboring  cells  and 
gives  rise  to  painful  sensations,  which  are  interpreted  as  coming 
from  the  area  supplied  by  the  stimulated  cells.  This  tendency  to 
diffusion  may  be  due : 

(a)  To  reduction  of  the  resisting  power  of  neighboring  seg- 
ments, "general  constitutional  diseases  reducing  the  body  powers 
generally,  and  the  nervous  system  in  particular,  as  in  anemia  and 
pulmonary  tuberculosis." 


PERIPHERAL    OBJECTIVE   PAINS  93 

(b)  Increasing  excitability  of  the  involved  segment,  as  in 
fevers. 

(c)  Prolonging  or  augmenting  the  stimulating  power  unduly, 
as  in  chronic  ovaritis  and  chronic  metritis. 

These  diffusely  distributed  pains  should  not  be  mistaken  as 
manifesting  hysteria  or  hypochondriasis.  In  some  cases  the  diffu- 
sion is  so  great,  and  the  pains  so  general,  that  they  are  spoken  of 
as  generalized  pains.  (This  is  particularly  so  in  the  various  in- 
fectious diseases.)  In  other  cases,  when  a  distant  segment  of  the 
cord,  or  even  the  pain  centers  in  the  brain,  have  a  reduced  resisting 
power,  or  have  had  the  pain  habit,  irritation  in  any  part  of  the 
body  may  sensitize  these  centers  and  cause  the  pain  to  appear  to 
come  from  their  areas  of  distribution.  From  Fromentel's  studies 
(Monro,  556)  it  appears  that  the  relationship  between  the  irri- 
tated point  and  the  sympathetic  point  is  very  constant  and  that 
the  sympathetic  point  is  generally  on  the  trunk  on  the  same  side 
of  the  body.     Cases  in  point  are : 

(1)  "Mrs.  H.,  aged  44;  married  late  in  life  and  never  was 
pregnant.  Health  has  been  fairly  good.  Several  years  ago  she  had 
an  attack  of  acute  otitis  media,  the  result  of  chronic  otitis  media 
in  the  right  ear.  For  some  time  the  patient  has  suffered  from 
dysmenorrhea,  but  the  pain  from  which  she  suffers  has  been  in 
the  right  ear  and  has  been  very  severe.  I  was  called  to  see  the 
patient,  but  before  I  got  to  her  house  the  pain  had  ceased.  The 
patient  visited  me  at  my  office.  Bimanual  vaginal  examination 
showed  an  enlarged  and  very  tender  left  ovary,  pressure  upon 
which  caused  quite  severe  pain  in  the  ear"  (personal  communica- 
tion from  Dr.  Torrey,  Olean,  ISTew  York). 

(2)  Pain  in  the  chest,  right  side  anterior,  from  rubbing  the 
back  of  the  right  forearm.  A  touch  on  the  back  of  the  forearm 
or  any  part  of  a  strip  of  surface  extending  from  below  the  elbow 
to  the  four  iiuier  metacarpo-phalangeal  articulations  was  felt  both 
locally  and  in  the  area  described  on  the  anterior  of  the  chest. 
Firm  pressure  on  the  part  of  the  arm  described  caused  no  pain 
locally,  but  caused  severe  tearing  pain  in  the  chest  front  (Monro, 
32,  p.  9). 


94  CLASSIFICATION   OF   PAIN 

(3)  Pain  in  the  chest,  due  to  pressure  at  the  front  of  the  wrist, 
at  the  root  of  the  thumb,  or  at  the  flexure  of  the  elbow  on  the  left 
side.  The  pain  caused  was  not  local,  but  was  felt  in  the  left  lateral 
region  of  the  chest  (Monro). 

(4)  Pain  was  present  in  the  chest  on  the  right  side,  over  the 
second  right  costal  cartilage,  during  each  dressing  of  an  appendi- 
ceal abscess  wound. 

(5)  Painful  stimulation  of  the  thigh  produced  a  pain  in  the 
back  of  the  head  (Monro,  32,  from  Dc  Fromeutal,  ''Les  Synalogus 
et  les  Sjnalgia"). 

(6)  Mitchell  quotes  a  case  where  stimulation  of  a  mole  on 
the  leg  produced  pain  in  the  chin. 

(7)  The  headache  which  occurs  after  eating  ice  cream  is  also 
an  illustration  of  this  variety  of  pain. 

(8)  The  headaches  which  occur  in  various  diseases  are  also 
illustrative  of  this  condition. 

(9)  Alger  (560)  reports  a  case  of  severe  abdominal  pain, 
resembling  that  due  to  appendicitis,  caused  by  eye-strain.  Upon 
the  adjustment  of  glasses,  the  pain  disappeared.  Three  years 
later  the  patient  lost  his  glasses,  and  the  pain  immediately  re- 
turned. 

In  some  cases  the  associated  areas  are  physiologically  related, 
as  the  breast  and  uterus  (see  mammary  gland).  It  is  very  com- 
mon for  women  to  have  pain  in  the  breast  during  the  period  of 
menstruation.  In  many  cases  it  occurs  just  prior  to  menstrua- 
tion. This  pain-localization  may  be  due  to  lessened  resistance 
or  increased  irritability  in  the  nerve-conducting  paths,  the  stimu- 
lus which  in  one  gives  rise  to  pain,  in  another  produces  no  reac- 
tion ;  or  there  may  be  some  unusual  nerve  'connections  between 
these  different  parts,  or  some  cryptogenic  process  may  lie  dormant 
in  the  parts  and  announce  its  presence  by  pain  on  irritation  of 
some  related  j^art.  In  woman,  the  sj)inal  area  offers  least  resist- 
ance to  pain  at  the  sixth  dorsal  (mammary)  ana  the  tenth  dorsal 
(ovarian)  vertebra. 

Misreference  of  pain  phenomena,  because  of  the  instability 


PERIPHERAL    OBJECTIVE   PAINS  95 

of  the  nervous  system  and  the  imperfect  development  of  the  local- 
izing apparatus,  is  very  common  in  children.  Examples  of  this 
are  seen  in  the  pain  present  over  the  appendix  area  in  cases  of 
pneumonia  and  hip-joint  disease. 

Referred  Paiist. — Referred  pain  is  the  name  given  to  that 
class  of  pain  in  which  the  irritation  occurs  along  the  course  of 
the  nerve  fibers,  and  the  pain  is  felt  as  being  produced  in  the 
somatic  peripheral  distribution  of  the  afi^ected  nerve  or  nerves. 
There  are  three  places  where  the  irritation  may  cause  referred 
pain,  namely: 

(a)  The  cord. 

(b)  The  posterior  roots  or  ganglia. 

(c)  The  nerve  trunks  or  nerves. 

When  the  irritation  occurs  in  the  cord,  the  pain  sensation  is 
referred  along  the  pain  paths  connected  with  the  same  side  of  the 
body.  When  it  is  transferred  across  the  cord,  and  is  felt  on  the 
opposite  side,  it  is  called  transferred  pain.  Among  referred 
pains,  due  to  disturbance  in  the  cord,  are  the  well-known  girdle 
pains,  which  are  almost  pathognomonic  for  tabes  dorsalis,  trans- 
verse myelitis,  cord  tumors,  etc.  Referred  pains  from  lesions  on 
the  posterior  roots  may  be  due  to  pressure  from  fragments  of  a 
fractured  vertebra,  tumors,  or  inflammation,  as  in  meningitis  and 
herpes.  The  principal  causes  of  referred  pain,  however,  are 
lesions  occurring  somewhere  on  the  nerve  circuit.  They  may 
occur  on  the  nerve  trunk  or  on  one  of  the  branches  (see  illustra- 
tion). When  a  lesion  occurs  on  the  trunk,  it  is  always  referred 
to  a  point  on  the  periphery  distal  to  the  area  at  which  it  occurs ; 
but  if  the  irritation  is  on  a  branch,  it  may  be  referred  to  the 
periphery  in  an  area  proximal  to  that  at  which  it  occurred.  This 
is  due  to  its  reference  along  a  collateral  branch.  Bennett  (-48) 
gives  a  number  of  cases  in  which  pain  in  the  groin  was  due  to 
both  downward  and  upward  reference. 

The  following  is  a  table  taken  from  Dr.  Bennett's  article 
(p.  269)  : 


06 


CLASSIFICATION   OF   PAIN 


Incidents  of  Pain  in  Groin 
Apparently  from  Above 

Cases 

Prolapse  of  ovary 1 

Omental  umbilical  hernia.  1 

Tumor  of  the  pelvis 1 

Stone  in  the  bladder 1 

Stone  in  the  ureter 3 

Stricture  of  the  urethra.  .  2 

Movable  kidney 1 

Cyst  of  the  testicle 2 

Retained  testicles   3 

Intestinal  diverticulum ...  1 

Incomplete  inguinal  hernia  2 

Traumatic  lumbar   hernia  1 

Varicocele 3 

Lateral   curvature    of    the 

spine 2 

Spinal  abscess 1 

Undetermined 2 


Incidents  of  Pain  in  Groin 
Apparently  from  Below 

Cases 

Small  omental  hernia.  ...  1 

Small  femoral  hernial  sac.  1 

Obturator  hernia 1 

Saphenous  varix 4 

Osteoma  of  the  tibia 1 

Femoral  atheroma 2 

Osteoarthritis 1 

Rider's  sprains    4 

Polypus  of  the  rectum ....  2 

Piles 2 

Plat  foot 1 

Popliteal  sarcoma 1 

Old  fractured  tibia 2 

Melanotic  mole  on  the  sole 

of  the  foot 1 

Varicocele   2 


Dr.  Bennett  also  speaks  of  a  case  of  osteoma  of  the  tibia,  in 
which  a  sharp  spicule  of  bone  sprang  from  the  inner  surface  of 
the  bone,  about  four  inches  from  its  lower  end.  Pressure  upon 
this  caused  acute  pains  in  the  left  groin,  rather  to  the  inner  side. 
Pain  also  occurred  when  the  limb  was  being  flexed,  as  well  as 
when  it  was  rotated  outward.  Kicking  also  caused  pain.  It  was 
due  to  involvement  of  a  filament  of  the  saphenous  nerve. 

Another  case  mentioned  by  Dr.  Bennett  is  that  of  a  pain  in 
the  knee  caused  by  a  corn.  In  this  case,  a  loose  semilunar  car- 
tilage was  diagnosed,  and  the  advisability  of  an  operation  was 
considered.  The  patient  had  sudden  attacks  of  acute  pain,  most 
marked  when  he  would  suddenly  turn  around.  These  pains  were 
present  when  he  wore  boots  or  shoes,  and  were  entirely  absent 
at  other  times. 

A  most  peculiar  case  was  one  in  which  pain  in  the  groin  was 


PERIPHERAL    OBJECTIVE    PAINS  97 

caused  by  a  mole  on  the  foot.  Pressure  upon  the  mole,  which 
"was  on  the  inner  side  of  the  foot,  caused  pain  in  the  front  of  the 
groin.     Other  cases  of  upward  reference  are : 

(1)  Pain  in  the  back  caused  by  a  wound  of  the  testicle  (Wit- 
mer,  527,  p.  930). 

(2)  Pain  and  tender  areas  over  the  fourth  and  fifth  spinal 
segments  in  painful  disease  of  the  breast  (Treves's  "Applied  An- 
atomy," p.  176). 

(3)  Pain  in  the  left  clavicle  in  volvulus  of  the  small  intes- 
tine; condition  verified  by  autopsy  (Ha worth). 

(4)  Pain  in  the  back,  due  to  a  w^ound  of  the  testicle  (S.  W. 
Mitchell,  559). 

Cases  of  downward  reference  are: 

(1)  Pain  in  the  arm  and  hand  from  pressure  on  the  brachial 
plexus  by  a  supernumerary  rib. 

(2)  Pain  in  the  little  finger  due  to  pressure  on  the  ulnar 
nerve  from  a  growth  on  the  first  rib  (Forsyth,  126,  p.  1470,  quot- 
ing from  Hilton). 

(3)  Pain  in  the  left  leg,  in  a  case  of  tubercular  disease  of 
the  spine,  with  a  sinus  opening  in  the  lumbar  region.  Upon 
passing  a  sound  into  the  sinus,  the  patient  complained  of  severe 
pain  shooting  down  the  leg  (St.  Francis  Hospital  Dispensary). 

(4)  Pain  in  the  hand,  along  the  outer  (radial)  side,  from 
irritation  of  the  musculospinal  nerve  due  to  fracture  of  the  upper 
part  of  the  middle  third  of  the  humerus  (Estes,  555).  Estes 
also  mentions  the  pain  felt  on  the  ulnar  side  of  the  hand,  especially 
in  the  little  finger,  in  cases  of  bone  excrescences,  etc.,  about  the 
inner  condyle  of  the  humerus. 

(5)  Pain  in  the  thigh  (anterior  and  posterior)  and  in  the 
groin,  from  a  psoas  abscess.  This  case  I  shall  give  in  detail  be- 
cause of  classical  reference  of  the  pain. 

The  patient  had  been  sick  for  some  weeks,  and  recently  com- 
plained of  pain  in  the  posterior  region  of  the  leg.  The  point  of 
maximum  tenderness  was  beneath  the  crural  fold  in  the  crural 
crease.  He  also  complained  of  pain  in  the  area  outlined  in  Fig.  34. 
There  was  a  fullness  present  in  the  inguinal  region,  which  was 


98  CLASSIFICATION   OF   PAIN 

tender  to  the  touch.  On  irritation  of  a  narrow  area  of  the  skin 
next  to  the  scrotum,  a  reflex  contraction  of  the  abdominal  wall 
was  noted  in  the  area  indicated  in  Fig.  35.  This  reflex  was  pres- 
ent on  both  sides.  There  was  also  noted  rigidity  of  the  spine, 
Sayre's  test  positive,  Bryant's  angle  normal.  When  lying  on  the 
back  or  side,  the  knee  was  flexed  and  the  thigh  but  slightly  flexed ; 
there  was  fullness  in  the  left  inguinal  space  glands,  as  indicated ; 
the  circumference  of  left  thigh  was  1.5  inches  more  than  the 
right  one.  This  condition  gradually  progressed  until  opera- 
tion, several  days  later,  when  a  large  collection  of  pus  was 
found  in  the  inguinal  region,  which  apparently  came  from  the 
region  of  the  spine.  After  operation,  the  patient  quickly  col- 
lapsed, his  temperature  became  high,  and  he  died  in  twenty-eight 
hours. 

It  is  interesting  to  speculate  upon  the  reason  Avhy  pain  should 
be  felt  in  the  area  indicated.  A  study  of  the  anatomy  shows  that 
the  area  of  j)ain  is  the  area  of  distribution  of  the  small  sciatic 
nerve,  which  was  involved  by  the  abscess  cavity  as  it  gradually 
crept  downward  into  the  thigh.  The  reflex  contraction  of  the 
lower  abdominal  wall  occurred  in  the  area  of  distribution  of  the 
first  lumbar  segment,  and  the  irritation  which  produced  it  was 
made  in  the  area  of  distribution  of  the  ilio-inguinal,  which  is  also 
derived  from  the  first  lumbar  segment  (Fig.  3G).  Thereiore, 
the  first  lumbar  segment  of  the  cord  in  this  instance  acted  but  as 
a  reflex  station  for  the  nerves  which  derived  their  origin  from  it. 
The  sudden  death  of  the  patient,  in  this  case,  could  only  be 
explained  by  the  supposition  that  the  system  was  overwhelmed  by 
toxins  which  were  more  easily  absorbed  when  the  pressure  was 
taken  away  from  the  cavity  walls  on  the  opening  of  the  abscess. 
Still,  this  is  a  rather  far-fetched  explanation. 

Other  cases  of  downward  reference  are: 

(1)  Pain  in  the  epigastrium,  due  to  disease  of  the 'spine, 
with  a  slight  displacement  between  the  sixth  and  seventh  ver- 
tebrae. In  this  condition,  the  pain  increased  when  the  patient 
assumed  an  erect  position,  and,  as  a  consequence,  he  walked  with 
the  body  inclined  forward  (Hilton). 


Si 

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as 


o 
o 

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P^ 

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P 
O 


Q 


111! 


O  S  C  C  3 


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99 


100  CLASSIFICATION   OF   PAIN 

(2)  Pain  in  the  chest,  in  the  distribution  of  the  fourth  and 
fifth  dorsal  nerves,  from  an  aneurysm  of  tlie  aorta  (Hilton). 

(3)  Pain  in  the  penis  from  ureteral  colic  and  from  cystitis. 
In  one  ease  the  patient,  who  had  a  stab  wound  one  inch  below  the 
umbilicus,  complained  of  pain  in  the  penis  each  time  the  gauze 
packing,  which  touched  the  bladder,  was  removed.  The  rectum 
and  the  neck  of  the  bladder  are  supplied  from  the  second, 
third  and  fourth  sacral  nerves.  From  the  same  nerves  the 
pudic  nerve,  supplying  the  penis,  is  derived,  and  thus  is  ex- 
plained the  pain  in  the  23enis,  due  to  rectal  or  vesicle  disorder 
(Monro,  32,  p.  7). 

(4)  Pain  in  the  great  toe  on  the  left  side,  in  a  patient  suf- 
fering with  perinephritic  abscess,  the  sinus  from  which  opened  in 
the  lumbar  region  a  half  inch  from  the  second  lumbar  vertebra. 
Pain  was  noticed  only  when  the  cavity  was  full  of  solution 
(E.  C.  Stuart,  personal  report). 

(5)  Disease  of  the  anterior  third  of  the  tongue  frequently 
causes  pain  in  the  auditory  canal,  because  the  auditory  canal,  the 
teeth,  and  the  anterior  part  of  the  tongue  are  all  supplied  by  the 
fifth  dorsal  nerve  (Monro,  32). 

(6)  Pain  in  the  legs,  which  was  very  unresponsive  to  treat- 
ment, was  found  to  be  due  to  a  tumor  of  the  cauda  equina. 

(7)  Monro  (32,  p.  7)  also  gives  an  example  of  a  case  of  hemi- 
plegia in  which  the  patient,  who  had  almost  complete  anesthesia 
of  the  genitals,  suffered  pain  in  the  great  toe  every  time  he  passed 
urine.  This  is  explained  by  ]\Ionro  as  due  to  the  common  origin, 
from  the  first  sacral  nerves,  of  the  nerves  supplying  the  dorsum 
of  the  gTeat  toe  and  those  supplying  the  prostate  and  the  mucous 
membrane  of  the  neck  of  the  bladder. 

(8)  Pain  in  the  calf  of  the  leg  may  be  present  in  prostatic 
disease  (Head,  ''Brain,"  16,  p.  29). 

(9)  Severe  earache  may  also  be  found  occasionally  in  ton- 
sillitis. 

(10)  Pain  on  the  inner  side  of  the  ankle  was  due  to  a  tumor 
in  Scarpa's  triangle. 

The  following  are  characteristics  of  pain  due  to  pressure  upon 


PERIPHERAL   OBJECTIVE   PAINS  101 

a  nerve  trunk  by  a  tumor,  enlarged  and  displaced  organs,  or  other 
causes: 

(1)  The  pain  is  continuous,  and  does  not  intermit,  as  in 
neuralgic  pain. 

(2)  It  is  not  increased  upon  pressure  or  movement. 

(3)  It  does  not  produce  muscular  stiffness,  differing  in  this 
respect  from  inflammatory  pains. 

(4)  It  may  interfere  with  function,  as  in  brain  tumor  or 
brain  abscess.  In  the  former  there  is  no  fever,  while  in  the  latter 
fever  is  present. 

(5)  It  radiates  very  widely,  especially  when  large  trunks  or 
plexuses  of  nerves  are  involved.  A  characteristic  of  radiating 
pains  is  that  they  vary  greatly  in  intensity  and  location,  but  that 
they  are  always  associated  with  other  pains  which  are  due  directly 
to  the  lesion  or  radiate  from  it.  A  study  of  the  different  varieties 
of  radiated  pain  will  give  us  a  clew  to  the  focus  of  the  disease. 

(6)  Tumor  involving  the  trunk  of  a  nerve  sometimes  causes 
trophic  changes  at  the  peripheral  distribution  of  the  nerve  on  the 
skin,  in  the  form  of  an  intractable  ulcer,  or  as  a  herpetic  eruption 
followed  by  persistent  local  anesthesia. 

(7)  Cramps  in  the  muscles  may  be  associated  with  pressure 
pains. 

(8)  A  point  in  connection  with  these  pains  is  that  morphin 
does  not  ease  them  for  any  considerable  time,  but  "antipyrin, 
phenacetin,  and  other  coal-tar  derivatives  are  of  considerable  ser- 
vice, either  combined  with  an  opiate  or  w^ith  bromids.  This  is 
especially  true  in  pains  caused  by  aneurysm"  (Thompson,  561). 

In  cases  of  section  of  nerves,  J.  K.  Mitchell  remarks  that  occa- 
sionally, after  union  of  the  segments  has  taken  place,  the  sensa- 
tions of  touch  and  pain  are  referred  to  the  wrong  areas.  He  sug- 
gests, by  way  of  explanation  of  such  cases  as  depend  upon  nerve 
injuries,  that  possibly,  in  the  union  of  the  several  nerve  trunks, 
the  axis-cylinders  in  the  proximal  part  do  not  always  succeed  in 
joining  the  proper  axis-cylinders  in  the  distal  portions.  For  in- 
stance, after  a  lesion  of  the  nerves  in  the  upper  arm,  nerve  fibers 
from  the  proximal  stump,  which  normally  convey  sensations  from 


102  CLASSIFICATION   OF   PAIN 

the  elbow  lesion,  may  unite  with  fibers  from  the  distal  part  and 
with  nerves  which  are  anatomically  connected  with  the  hand. 
Thus,  the  impression  due  to  a  touch  on  the  hand  will,  on  reaching 
the  seat  of  injury,  be  shunted  to  the  path  hitherto  for  impressions 
from  the  elbow.  The  sensorium  soon  learns  to  orient  the  sensa- 
tions so  they  are  referred  to  their  proper  source. 

A  differential  diagnostic  point  between  referred  pain  and  neu- 
ralgia is  that  in  referred  pain.no  nodal  points  are  present  (J.  H. 
Musser,  558).  Apropos  of  this  subject,  and  bearing  upon  the 
production  of  pain,  Carleton  (123)  reports  cases  of  referred, 
transferred  and  reflex  pain,  in  which  relief  was  obtained  by  the 
local  application  of  adrenalin,  over  the  terminal  nerve  filaments 
or  in  the  course  of  the  nerve.  It  is  difficult  to  understand  the 
modus  operandi  of  this  relief,  because  it  is  not  reasonable  to  sup- 
pose that  adrenalin,  when  locally  applied,  can  have  any  but  a  local 
action;  and  if  it  does  have  only  a  local  action,  how  is  it  possible 
that  it  can  affect  the  seat  of  production  of  pain,  which  may  be 
some  distance  away,  on  the  same  nerve  or  on  an  entirely  different 
nerve,  either  on  the  same  or  on  the  opposite  side  of  the  body  ?  It 
may  be  that  the  application  of  adrenalin  produces  some  effect  on 
the  nerves,  so  that  the  transmission  of  painful  impulses  is  in- 
hibited. Carleton  supposes  the  effect  to  be  due  to  a  regeneration 
of  the  nerve  force,  or  rather  the  restocking  of  the  nerve  with  kinet- 
oplasm,  the  substance  consumed  in  the  nerve  cells  during  their 
activity.    How  it  does  so  is  to  me  incomprehensible. 

Sympathetic  Pain. — Closely  resembling  transferred  pain  is 
sympathetic  pain.  It  is  really  a  transferred  pain,  with  the  dis- 
tinction that  in  sympathetic  pain  a  painful  sensation  is  present 
in  the  organ  originating  the  pain,  while  in  transferred  pain  there 
may  be  no  painful  impression  or  sensation  in  the  area  or  organ 
in  which  the  pain  originates.  In  other  words,  sympathetic  pain 
is  an  overflow  phenomenon,  while  transferred  pain  is  due  to  con- 
veyance of  the  stimulus  through  collateral  fibers  from  one  cord 
segment  to  another  which  is  either  adjacent  to  or  at  a  distance 
from  it.  As  an  example  of  sympathetic  pain,  we  have  the  pain 
in  the  axilla  passing  down  to  the  arm  and  hand,  due  to  angina 
pectoris.     The  axilla,  arm,  hand,  and  heart  are  supplied  by  con- 


PERIPHERAL  OBJECTIVE   PAINS  103 

tiguous  nerve  roots,  the  third,  second,  and  first  dorsal  (McKen- 
zie),  and  thus  a  stimulation  of  one  segment  is  conveyed  to  the 
adjacent  segment  and  the  sensation  is  referred  to  the  peripheral 
distribution  of  these  segments. 

Projection  Pain. — Closely  allied  to  referred  pain  is  projec- 
tion pain,  a  term  given  to  pain  which  is  felt  as  being  present  either 
in  a  part  which  has  no  sensation  (as  in  locomotor  ataxia),  or  in 
a  part  which,  because  of  amputation,  no  longer  exists.  In  the 
case  of  projection  pain  in  an  amputated  limb,  the  pain  seems 
to  be  due  to  the  inclusion  of  the  nerve  in  the  cicatrix  of  the  stump, 
or  a  neuritis,  or  a  neuroma.  Neuromata,  however,  do  not  cause 
pain  unless  they  become  adherent  to  the  adjacent  tissues.  It  is 
also  related  in  some  way  to  the  circulation.  Otherwise  how  can 
the  relief  derived  from  elevation  of  the  stump  be  explained?  In 
amputations  about  one  half  the  cases  the  sensation  is  that  the 
intermediate  part  is  missing  and  that  the  limb  is  gradually  becom- 
ing shorter  until  the  sensation  is  that  the  hand  or  foot  is  attached 
directly  to  the  amputated  part.  Gordon  (562)  enters  into  the 
psychology  of  the  subject  to  a  considerable  degree.  Every  con- 
ception of  a  limb  is  due  to  a  visualization  of  the  peripheral  stim- 
uli which  have  been  received.  When  irritation  is  present  in  the 
periphery  of  any  amputated  nerve,  the  visualization  is  still  pres- 
ent, and  from  old  association  produces  a  picture  of  the  absent 
limb.  It  is  along  this  limb  to  the  former  distribution  area  of 
the  various  nerve  fibers  that  the  pain  is  referred. 

Gordon  illustrates  the  visualization  of  an  amputated  arm,  in 
which  pain  finally  developed,  in  the  case  of  "a  railroader  who 
met  with  an  accident  twenty-seven  years  previous,  in  which  his 
left  arm  was  crushed  and  amputated.  Since  the  operation  he  has 
always  felt  the  presence  of  the  left  arm.  Soon  pain  developed, 
which  was  localized,  mentally,  so  to  speak,  in  the  left  limb.  The 
severity  of  the  pain  gradually  disappeared,  though  the  pain  itself 
did  not  cease.  Upon  examination,  the  stump  appears  to  be  cov- 
ered with  a  cicatrix.  The  latter  is  tender,  and  pressure  upon  it 
causes  a  sharp  pain,  which  extends  downward  along  the  absent 
limb.  The  prick  of  a  pin  will  also  cause  pain  to  be  referred 
down  the  limb.     If  cold  or  hot  water  is  applied  to  the  stump,  a 


104  CLASSIFICATION    OF   PAIN 

sensation  of  cold  or  heat,  respectively,  will  be  felt  by  the  patient 
down  the  absent  limb,  as  far  as  the  tips  of  the  imaginary  fingers. 
He  also  has  spontaneous  sensations  of  the  absent  limb,  and  con- 
stantly feels  the  presence  of  the  arm.  He  feels  it  hanging  along- 
side of  the  body ;  he  feels  the  arrangement  of  the  fingers  and  some- 
times their  movements.  There  is  a  constant  unpleasant  feeling, 
a  numbness  in  the  absent  limb.  He  also  has  at  times  a  spontane- 
ous, sharp  pain,  of  neuralgic  character,  which  makes  him  fiinch 
and  double  up.  This  pain,  he  says,  runs  through  the  ulnar  side 
of  the  arm.  A  few  months  ago,  the  patient  suffered  an  apoplectic 
seizure,  following  which  a  left  hemiplegia  developed.  Since  this 
cerebral  disturbance,  the  former  stump  phenomenon  became  ag- 
gravated. The  spontaneous  pain  in  the  absent  arm  is  more  fre- 
quent and  intense,  the  numbness  causes  him  more  discomfort  than 
previously,  and  finally  the  response  to  stimulation  of  the  stump  is 
decidedly  greater." 

Reflected  Pai^st. — The  next  variety  of  pain  which  we  shall 
consider  under  reflected -(deflected)  pain  is  that  in  which  the  stim- 
ulus is  carried  to  the  sensory  ganglia  or  to  the  cord  and  then  trans- 
ferred from  the  sensory  filaments  of  the  neuron  primarily  affected 
to  those  of  a  secondary  neuron.  The  stimulus  is  then  carried,  in 
this  neuronic  pathway,  to  the  brain,  and  is  perceived  as  coming 
from  the  distribution  area  of  the  second  neuron.  This  variety  of 
pain  differs  from  referred  pain  in  that  in  reflected  pain  there  is  a 
transfer  of  painful  stimuli  from  one  neuronic  system  to  another, 
while  in  referred  pain  there  is  no  transfer  but  only  a  misreference 
of  the  pain  by  the  sensorium.  A  better  term  to  express  the  true 
characteristic  of  this  variety  of  pain  would  be  "deflected,"  instead 
of  "reflected"  or  "reflex."  "Deflect"  means  to  turn  aside,  or  to 
shunt,  while  "reflex"  means  to  turn  back ;  and,  since  the  pain  is 
not  turned  back,  but  is  only  swerved  into  another  pathway,  it 
seems  that  "deflection"  would  characterize  the  change  more  than 
would  "reflection."  Besides,  in  physiology  "reflection"  is  gener- 
ally used  to  indicate  a  reaction  produced  in  some  portion  of  the 
body  by  a  «hange  in  another  part ;  and  for  this  reaction  "afferent 
and  efferent  fibers  are  necessary.     The  former  are  of  a  necessity 


PERIPHERAL    OBJECTIVE    PAINS  105 

sensory;  the  latter  may  be  motor,  vasomotor,  vasoinhibitory,  car- 
dioinhibitory,  or  secretory.  They  are  never  sensory,  for  the  simple 
reason  that  a  sensory  nerve  is  always  afferent,  and  there  can  be 
no  reflection  without  descending  fibers"  (Hart,  273,  p.  344),  so 
that  it  would  seem  to  be  better  to  use  deflection  instead  of  reflec- 
tion. These  deflections  probably  have  an  anatomical  basis.  Re- 
cent researches  show  that  the  nerve  cells  (in  a  segment)  of  the 
cord  undergo  degeneration  as  a  result  of  any  lesion  in  the  corre- 
sponding segmental  distribution  area  (Lickley,  138,  p.  438). 
This  confirms  the  hyj)othesis  that  stimuli  causing  pain  arise  from 
direct  irritation  from  pathological  changes  in  the  cord,  and  are  not 
due  simply  to  a  transfer  of  stimuli  from  one  set  of  cells  to  another. 
The  most  numerous  and  important  of  reflected  (deflected) 
pains  are  those  due  to  pathological  changes  in  the  internal  viscera. 
The  viscera  of  themselves  have  no  sensation  of  pain,  as  elicited 
by  ordinary  pain-producing  stimuli.  They  can  be  cut,  torn  and 
sutured  without  the  production  of  pain ;  likewise,  they  are  insensi- 
tive to  heat  and  cold,  but  have  a  sense  of  their  own  which  tells 
the  sensorium  of  their  well-being  with  a  sensation  akin  to  that 
which  we  term  muscle-sense,  or  joint-sense.  AVhen  the  viscera  are 
irritated,  the  stimuli  are  carried  to  the  cord  and  react  on  the  cord 
cells;  and  impulses  are  produced  and  sent  out  as  motor  impulses, 
or  are  carried  to  the  brain  by  the  neurons  of  these  cells,  where 
they  are  perceived  as  painful.  At  the  same  time,  the  adjacent  set 
of  cells  become  irritable,  and  react  abnormally  to  all  stimuli  reach- 
ing them  from  the  periphery.  Thus,  we  have  the  origin  of  the 
hyperalgesic  zones  of  Head.  These  zones  are  not  always  present 
over  the  area  of  the  involved  viscera,  and  the  reason  for  this,  as 
given  by  McKenzie,  is  that  in  the  course  of  development  the  tis- 
sues, which  in  a  low  form  of  life  must  immediately  have  covered 
the  organ,  became  displaced.  In  this  way,  several  peculiarities  of 
pain-production  may  be  explained.  For  instance,  the  pain  in  the 
testicle  in  ureteral  colic  is  felt,  because,  in  early  fetal  life,  the 
testicle  was  very  high  in  the  abdomen,  and  was  supplied  by  the 
first  lumbar  segment.  Then  it  began  to  journey  through  the  ab- 
dominal ring  and  into  the  scrotum;  but  it  always  retained  its 


106  CLASSIFICATION    OF    PAIN 

nerve  supply.  The  ureter,  likewise,  receives  its  nerve  supply  from 
the  same  segment,  so  that  when  irritation  occurs  in  the  ureter  the 
pain  is  often  referred  to,  and  is  felt  as  arising  in  the  testicle, 
which  at  the  same  time  is  tender.  In  renal  colic  the  skin  of  the 
scrotum  is  never  hyperalgesic,  because  the  scrotum  is  supplied  by 
the  sacral  nerves;  but  the  deep  coverings  of  the  testicle  are  always 
hyperalgesic,  because  they  are  in  relation  with  the  same  cord  seg- 
ment as  the  kidney  (McKenzie). 

The  method  of  localizing  the  viscus  causing  the  reflected  pain 
is  given  below: 

(1)  Determine  if,  in  connection  with  it,  there  is  an  asso- 

ciated area  of  hyperalgesia. 

(2)  Delimit  the  area  of  hyperalgesia  as  nearly  as  possible, 

and  orient  it  with  a  cord  segment. 

(3)  Find  out  what  organs  are  supplied  by  this  segment. 

(4)  Examine  the  organ  or  organs  for  disease. 

(5)  See  if  the  pain  can  be  reproduced  by  manipulation  of 

the  organ. 

The  general  lowering  of  the  vitality  of  a  patient  often  aids  in 
the  production  of  reflected  pains  by  reducing  the  resistance  and 
increasing  the  irritability  of  the  affected  cord  segment.-^ 

Sometimes  reflected,  referred,  or  transferred  pains  are  con- 
fused with  neuralgia ;  from  this  they  can  be  differentiated  by  the 
injection  of  cocain,  which  will  ease  the  pain  of  a  neuralgia,  but 
will  have  no  effect  on  referred  pain. 

Transfeeked  Pain. — Transferred  pain  is  the  name  given  to 
that  variety  in  which  the  stimulus  passes  from  the  neuron  in  which 
it  is  originally  present,  over  an  intermediate  neuron,  to  a  third 
neuron,  in  the  area  of  distribution  of  which  it  is  perceived  as 
being  present. 

In  other  cases  the  sensorium  may  mistake  the  peripheral  dis- 
tribution of  the  pain,  as  in  degeneration  of  the  posterior  roots 
(tabes),  or  of  the  ganglia  and  posterior  columns,  or  cornu  of  the 

'  For  a  more  complete  exposition  of  this  subject,  see  under  Head's  Zones, 
Visceral  Sensibility 


PERIPHERAL    OBJECTIVE    PAINS  107 

cord.  It  is  very  likely  that  in  certain  conditions  the  sensory  im- 
pulses which  are  carried  by  the  sensory  fibers  and  the  gi'ay  matter 
are  not  entirely  obtunded  or  destroyed  by  the  pathologic  processes 
which  have  taken  place,  so  that  touch  can  be  conveyed  to  a  minor 
degree,  and  localizing  sensations,  such  as  those  which  tell  us  of  the 
position  of  a  limb,  may  be  present  only  in  a  very  restrictive  sense. 
Therefore,  an  impulse  propagated  through  the  sensory  pathways 
is  very  weak,  and  on  its  perception  by  the  brain  (there  being  little 
or  no  localizing  stimulus  accompanying  it),  is  perceived  as  coming 
from  the  opposite  side  where  the  localizing  neurons  are  intact. 

When  the  transference  occurs  in  the  cord,  the  segment  affected 
may  be  homologous  to  the  segment  in  whose  area  the  impulse  was 
originally  received,  or  it  may  be  higher,  or  it  may  be  lower.  In 
the  latter  cases  the  impulse  is  transmitted  to  the  perceptive  (third) 
neuron  through  some  of  the  collateral  branches. 

Examples  of  pain  transferred  to  a  homologous  segment  in  the 
same  relative  position  on  the  opposite  side  of  the  abdomen  are 
found  in  appendiceal  and  ovarian  diseases,  pneumonia,  and 
pleurisy.  Examples  of  higher  and  lower  reference  are  found  in 
those  cases  in  which  the  pain  of  pneumonia  is  transferred  to  the 
appendiceal  region,  or  in  which  the  appendix  causes  pain  which 
is  transferred  to  the  thorax.  Mitchell  (559)  cites  two  instances 
of  this  variety  of  pain.  In  the  first  case  a  window  fell  on  a  finger 
upon  which  there  was  a  felon.  The  pain  was  felt  in  the  finger, 
and  at  the  same  time  iii  the  face  and  neck  on  the  opposite  side 
of  the  bod}'.  The  second  case  is  that  of  a  patient  who  had  a  heavy 
weight  fall  upon  his  right  foot,  striking  the  toes.  The  great  toe 
and  the  one  next  to  it  were  injured.  Immediately  pain  was  felt 
on  the  antero-internal  aspect  of  the  opposite  leg,  at  the  junction 
of  the  upper  and  middle  thirds.  The  pain  was  of  a  burning  char- 
acter, fairly  constant,  and  worse  at  night.  It  persisted  for  three 
weeks  longer  than  the  pain  in  the  injured  part.  The  case  has  also 
been  cited  of  pain  in  the  left  thumb  caused  by  a  felon  on  the  right 
thumb.  In  another  instance  a  wound  on  the  right  side  of  the 
neck  caused  paralysis  and  pain  in  the  left  arm  (Mitchell,  559). 
Mitchell  also  mentions  a  case  in  which  a  shell  wound  in  the  right 


108  CLASSIFICATION    OF    PAIN 

leg  caused  the  patient  to  complain  of  a  burning  pain  in  both  the 
left  and  the  right  arm  and  in  the  right  pectoral  region. 

In  regard  to  the  cause  for  the  persistence  of  these  pains,  I  shall 
quote  from  Dr.  Mitchell  (559),  who  says  that  "one  can,  in  a  meas- 
ure, comprehend  that  a  violent  stimulus  to  a  sensory  nerve  can  be 
switched  off  on  to  other  nerve  tracks  or  centers,  as  if  it  were  the 
escape  of  an  overcharge ;  but  even  if  we  hazard  such  a  hypothesis, 
it  is  still  difficult  to  explain  the  persistency  of  these  transferred 
impressions,  for  it  is  a  law  of  the  receiving  centers  for  painful 
impressions  that  when  the  cause  of  the  pain  ceases  to  be  active 
the  feeling  of  being  hurt  ends.  But  in  some  of  these  examples 
of  false  reference  of  pain  there  must  have  been  made  in  the  center 
some  more  or  less  permanent  change  that  continuously  represents 
the  effect  to  which  any  pain-producing  agency  usually  gives  rise." 

I  have  noticed  that  pain  is  more  likely  to  be  referred  to  the 
opposite  side  from  that  on  which  the  lesion  is  located,  in  elderly, 
unmarried  females.  What,  if  any,  bearing  their  social  state  has 
upon  this  fact  I  am  unable  to  say. 

Character  of  the  Pain. — Another  classification  of  pain  is  that 
founded  upon  the  description  furnished  by  the  patient.  This  is 
most  varied.  A  patient  with  a  lively  imagination  can,  of  course, 
give  a  more  vivid  description  of  pain  than  one  of  a  somewhat 
duller  mentality.  ISTaturally,  the  pain  is  likened  to  some  sensa- 
tion which  has  been  experienced  in  the  past;  hence  the  terms: 
burning,  gnawing,  cutting,  pinching,  smarting,  lancinating,  bor- 
ing, shooting,  screwing,  gripping,  stabbing,  grinding,  sharp,  dull, 
aching,  lightning,  tearing,  creeping,  throbbing. 

In  earlier  times  this  method,  founded  on  the  description  of 
the  patient,  was  the  one  usually  employed ;  and,  with  the  tendency 
of  the  age  to  scholasticism,  pains  were  elaborated  and  defined  until 
a  celebrated  physician  of  the  time  of  Trajan  recognized  thirteen 
varieties,  and,  not  to  be  outdone,  Halmeman,  another  early  physi- 
cian, distinguished  seventy-five.  Avicenna,  in  the  tenth  century, 
A.  D.,  wrote  a  work  on  medicine,  in  which,  among  other  matters, 
he  distinguished  fifteen  varieties  of  pain  (Allen,  563). 

This  method  of  classification,  however,  proves  very  unreliable, 


PERIPHERAL    OBJECTIVE   PAINS  109 

because  of  the  difference  in  susceptibility  of  different  people,  and 
of  their  varied  powers  of  expression.  Yet,  it  is  of  some  value  in 
diagnosis,  for  certain  pains,  as  described  by  the  patient,  are 
characteristic  of  certain  disease  (Church  and  Peterson,  p.  960), 
as  the  lightning  pain  in  tabes,  the  gnawing  pain  in  rheumatism, 
the  burning  pain  in  neuritis,  the  girdle  pain  in  spinal  disease,  the 
lead-cap  pressure  pain  in  neurasthenia,  the  sharp,  cutting  pain  in 
neuralgia,  and  the  dull,  aching  pain  in  infectious  diseases. 

Persistency  of  Pain. — Pain  is  divided,  according  to  persist- 
.ency,  into  constant,  intermittent  and  remittent.  Each  of  these 
may  again  be  divided,  according  to  the  subjective  feeling,  into 
dull,  aching,  etc.  Likewise  each  may  be  classed  under  some 
variety  of  the  anatomical  divisions  of  pain,  as  referred  or  re- 
flected. When  a  pain  is  constant,  it  is  necessary  to  investigate 
those  conditions  which  act  constantly  and  which  produce  pain. 
Among  the  most  common  causes  of  constant  pain  are  new  growths 
pressing  upon  the  nerve  fibers  somewhere  in  their  course.  This 
pain  is  referred  to  the  peripheral  distribution  of  the  affected  fibers. 
Should  the  pressure  be  produced  by  an  inflammatory  mass,  the 
pain  is  constant,  but  is  marked  by  periods  of  lessened  severity. 
These  periods  indicate  the  intervals  in  which  the  inflammatory 
congestion  is  diminished.  In  other  cases  the  remission  may  be 
complete,  and  the  patient  may  be  free  for  a  shorter  or  longer  inter- 
val, as  in  salpingitis  and  oophoritis,  in  which  frequently  the  pain 
is  absent  during  intermenstrual  periods,  and  reappears  when  the 
menstrual  congestion  occurs  and  the  blood  pressure  and  internal 
congestion  in  the  affected  organs  are  again  increased. 

Under  certain  conditions,  pain  may  occur  in  paroxysmal  at- 
tacks of  great  severity,  to  which  the  term  crises  has  been  given. 
According  to  Fenwick,  who  quotes  from  H.  C.  Moore,  a  pain  crisis 
consists  of  a  paroxysm  of  pain  as  violent  as  human  nature  can 
endure,  accompanied  by  excessive  functional  activity  of  the  part 
attacked,  but  disappearing  as  rapidly  as  it  appeared,  and  is  asso- 
ciated with  a  condition  of  undisturbed  functional  activity  of  the 
affected  viscera  between  the  paroxysms  (Fenwick,  569). 


110  CLASSIFICATION    OF    PAIN 

Time  of  the  Pain. — Pain  may  be  further  divided  into  diwnal 
and  nocturnal.  Diurnal  pains  are  worse  in  all  those  condi- 
tions which  are  aggravated  by  activity,  either  mental  or  physical. 
For  this  reason  neurasthenics  and  those  afflicted  with  diseases  of 
the  locomotor  apparatus  suffer  more  during  the  daytime.  Such 
conditions  are  found  in  rheumatism,  neuralgias  (as  sciatica),  flat 
foot,  joint  disease,  etc.  Pain  is  also  greater  during  the  day  in 
eye-strain  and  diseases  of  the  eye,  and  also,  as  a  rule,  in  diseases 
of  the  gastrointestinal  tract.  This  is  due,  in  both  cases,  to  the  fact 
that  during  this  time  the  organs  are  most  active.  Yet,  as  a  rule,, 
it  seems  that  nocturnal  pain  is  more  frequent  than  diurnal  pain. 
When  pain  is  present  during  both  periods,  it  is  more  severe  at 
night,  because  during  the  day  the  mind  has  so  many  other  affairs 
to  occupy  its  attention  that  it  does  not  perceive  the  pain  sensations 
as  acutely  as  it  would  if  it  were  free  of  other  impressions.  At 
night  everything  is  quiet,  the  other  senses  are  in  abeyance,  and  the 
pain-sensation  enters  and  alone  occupies  the  mentality. 

Among  pains  which  are  prominent  at  night  are  those  due  to 
syphilis,  uremia  and  gout.  Schmidt  (564,  p.  68),  in  speaking  of 
these  conditions,  says :  "It  seems  that,  as  a  result  of  the  diminu- 
tion of  the  metabolic  function,  through  the  absence  of  muscular 
work,  there  is  a  decrease  in  respiratory  and  cutaneous  activity. 
Therefore,  when  a  dyscrasia  exists,  the  toxic  curve  ascends  at  night 
and  leads  to  nocturnal  attacks  of  pain.  The  pain  of  tuberculous 
hip-disease  is  also  most  pronounced  during  the  night.  In  this 
disease  when  night  comes  on  and  the  patient  is  asleep  he  often 
cries  aloud  and  awakens  complaining  bitterly  of  the  pain  in  his 
hip.  It  is  claimed  that  the  pain  is  due  to  a  relaxation  followed  by 
a  sudden  contraction  of  the  muscles  around  the  joint.  During  the 
day  they  are  contracted  and  hold  the  limb  in  such  a  position  that 
the  least  possible  injury  can  be  done  to  it.  During  the  night  these 
muscles  relax  and  the  limb  falls  away  until  slight  pain  results. 
Then  the  muscles  sharply  contract  and  draw  it  again  to  the  posi- 
tion of  least  pain ;  but  as  they  do  so,  they  also  throw  the  head  of 
the  bone  forcibly  into  contact  with  the  acetabulum,  and  thus  cause 
the  sudden,  sharp,  acute  pain,  of  which  the  patient  so  complains." 


PERIPHERAL    OBJECTIVE    PAINS  111 

Colics  are  also  most  pronounced  during  the  night.  Schmidt 
(564,  p.  64)  says:  "It  seems  that  a  relationship  exists  between 
smooth  muscle  fibers  and  striped  ones,  so  that  when  one  set  is 
active  the  other  is  idle.  During  the  day  the  striped  muscle  fibers 
are  active,  and,  as  a  consequence,  the  smooth  ones  are  idle,  while 
the  smooth  ones  become  active  during  the  night,  when  the  striped 
ones  are  idle." 

Gall-stone  and  appendicitis  pains  are  frequently  present  at 
night,  many  hours  after  the  ingestion  of  food.  (For  fuller  dis- 
cussion, see  Gall  Stones  and  Appendix.) 

When  a  patient  gives  a  history  of  pain  occurring  at  particular 
times  one  should  inquire  as  to  his  habits  of  life,  what  his  routine 
of  work  is,  how  and  when  he  eats,  and  if  the  pain  seems  to  be  asso- 
ciated with  the  ingestion  of  food.  If  it  does,  one  should  ascertain 
if  it  follows  the  ingestion  of  all  varieties  of  food,  or  only  certain 
varieties,  and  inquire  whether  the  pain  is  relieved  by  the  ingestion 
of  food.  Hunger  headaches  and  hyperacidity  pains  in  the  stomach 
areas  and  pains  of  duodenal  ulcer  are  eased  by  the  taking  of  food, 
particularly  albuminous  foods. 

In  some  cases  the  pain-sensation  travels  more  slowly  than  is 
normal,  the  so-called  delayed  pain.  In  these  the  touch-sensation 
is  present  some  time  previous  to  the  pain-perception.  Tabes  dor- 
Balis  gives  such  a  pain-reaction.  It  may  be  observed  by  pricking 
the  patient  with  a  pin  and  having  him  say  "l^ow"  when  he  per- 
ceives the  sensation  of  touch,  and  "Oh"  when  the  sensation  is  pain- 
ful. He  will  say  "'Now"  much  earlier  than  "Oh,"  showing  that 
the  pain-perception  is  delayed.  It  is  hardly  possible  that  the 
delay  occurs  in  the  transmission,  for  it  seems  that  all  impulses 
travel  along  the  nerve  with  equal  speed ;  yet,  such  is  the  explana- 
tion given  by  Landois  ("Physiology,"  p.  936,  American  trans- 
lation, 1904). 

Sensitiveness  to  Pain. — It  seems  that  sensibility  to  painful 
impressions  is  present  in  early  infancy,  but  is  not  as  acute  as  in 
later  life.  The  infant,  at  the  time  of  its  birth,  I  have  no  doubt, 
is  able  to  receive  the  impressions  which  later  it  interprets  as 
painful ;  but  it  requires  time  to  learn  to  coordinate  the  sensory 


112  CLASSIFICATION    OF    PAIN 

impressions  and  classify  them  as  beneficent  or  harmful,  so  that  at 
this  early  age  pain-perception  has  not  as  yet  entered  into  its  con- 
sciousness. We  may  say  that  the  infant  has  an  instinctive  dread 
of  all  sensations  which  betoken  an  act  or  condition  detrimental 
to  its  welfare.  This  protective  and  defensive  instinct  is  an  in- 
herent and  non-cognitive  factor  in  its  development,  arising  not 
from  previous  experiences,  but  from  some  inherited  and  latent 
consciousness  which  awakes  under  the  stimulus  of  external  life 
and  takes  upon  itself  the  defense  of  the  organism  through  the 
perception  of  all  pernicious  impulses  as  disagi-eeable  sensations 
(principally  as  pain)  from  which  it  is  wise  to  be  dissociated.  As 
the  infant  develops,  it  becomes  more  sensitive  to  all  painful  im- 
pressions until,  in  adult  life,  it  probably  has  reached  the  acme 
of  sensitiveness.  From  this  period  until  middle  age  the  perceptive 
powers  probably  are  stationary.  Then,  as  age  advances,  they 
again  become  reduced,  until  in  old  age  they  are  once  again  at  a 
minimum.  As  the  ability  to  withstand  pain  differs  at  different 
ages,  it  also  differs  among  races  and  individuals  of  the  same  race. 
Among  races,  it  is  claimed  that  the  Hebrew  stands  pain  less  easily 
than  any  other  race  (Editorial,  British  Medical  Journal,  April 
14,  1906,  p.  880).  Such  general  statements,  however,  smack  of 
the  feuilletonist  and  are  not  to  be  taken  too  seriously. 

Individual  Susceptibility. — Among  individuals,  the  ability  to 
withstand  pain  varies  markedly.  It  seems  that  those  of  a  fair 
and  very  delicate  skin  are  most  susceptible.  In  these  people  the 
pain-receptors,  because  of  the  lack  of  protection  which  is  given  by 
a  thick  epidermis,  are  more  exj^osed  and  possibly  more  subject  to 
irritation  than  in  those  of  a  thicker  integument.  Such  people  are 
not  only  very  susceptible  to  pain,  but  also  to  cutaneous  irritability 
of  any  kind.  Others,  because  of  lack  of  mental  development,  are 
incapable  of  acute  perception  of  pain ;  while  still  others,  because 
of  intense  will  power,  or  of  some  inherent  inability  to  perceive 
pain,  are  comparatively  immune.  Bennett  mentions  such  a  case 
of  stoical  disregard  for  pain.  A  celebrated  Trench  surgeon  was 
performing  an  amputation,  and,  seeing  the  look  of  distress  on 
the  face  of  the  patient,  said:     "I  fear  I  am  causing  you  great 


PERIPHERAL    OBJECTIVE   PAINS  113 

pain,"  to  which  the  patient  replied:  "No,  the  pain  is  nothing; 
but  the  noise  of  the  saw  sets  my  teeth  on  edge." 

Ottolenghi  (449),  who  made  records  of  cases  of  six  hundred 
and  eighty-two  women,  found  that  women  were  less  sensitive  than 
men,  and  draws  the  following  conclusions  in  regard  to  pain  in 
women  at  different  ages.  He  states  that  the  sensitiveness  is  less 
in  early  life,  increases  to  the  twenty-fourth  year,  and  then  de- 
creases. This  sensitiveness  is  greatest  in  the  nineteenth  year. 
The  higher  the  type,  the  greater  the  sensibility.  The  left  temple 
and  left  hand  are  more  sensitive  than  the  right.  Luxury  seems 
to  increase  susceptibility  to  pain-perception.  The  divisions  of 
womanhood,  in  order  of  susceptibility  to  pain,  are:  (1)  girls  of 
wealthy  classes;  (2)  self-educated  women;  (3)  business  women; 
(4)  university  women;  and  (5)  washerwomen.  We  have  here  a 
generalization  which  must  be  taken  "cum  gi-ano  salis." 

Tissue  Susceptibility. — Tissues  vary  in  susceptibility  to  pain. 
Metzinger  (328,  p.  141)  claims  that  the  blood  supply  of  an  organ 
often  determines  its  sensitiveness  to  pain,  as  the  organs  which  are 
the  richest  in  blood  supply  generally  suffer  the  greatest  pain,  and 
that  organs  poor  in  blood  supply  have  little,  if  any,  pain.  This  is 
in  accordance  with  the  theory  of  Oppenheimer,  who  claims  that 
the  pain  is  created  and  carried  by  the  vasomotor  system.  As  ex- 
amples of  the  effect  of  blood  supply,  he  cites  the  lack  of  pain  in 
cartilage,  nails,  and  hair,  and  the  slight  pain  in  pneumonia,  while 
pain  is  present  to  an  enormous  degTee  in  the  periosteum,  perimy- 
sium, pleura,  peritoneum,  etc.  He  gives  bone  as  an  example  of  a 
tissue  which  is  free  from  pain,^  but  he  says  that  this  is  due  to  the 
fact  that  when  blood-vessels  enter  the  compact  structure  of  the 
bone  they  discard  their  muscular  coat  and  so  lose  the  vasomotor 
nerves  and  the  pain  sense.  These  sympathetic  vasomotor  fibers 
are  supposed  to  issue  by  the  post  root,  with  the  sensory  fibers,  and 
enter  the  spinal  ganglia.  In  the  cord  they  can  be  traced  to  the 
antero-lateral  ascending  tract.  Some  fibers  pass  to  the  anterior 
horn,  and  still  others  to  higher  or  lower  ganglion  cells. 

1  In  recent  experiments  we  have  found  that  the  meJullary  cavity  of  bon© 
is  very  sensitive. 


CHAPTER  VII 

THE  INTENSITY  OF  PAIN 

It  is  always  interesting,  and  in  some  cases  important  for  the 
diagnosis,  to  know  the  intensity  of  the  pain  suffered  by  the  pa- 
tient. The  patient  should  always  be  interrogated,  therefore,  re- 
garding this  point.  Often  the  answer  is  of  considerable  impor- 
tance in  enabling  the  clinician  to  make  a  diagnosis;  but  when  the 
physician  takes  the  word  of  the  patient  he  is  apt  to  be  misled, 
perhaps  not  intentionally,  yet  misled,  nevertheless,  because,  in  the 
great  anxiety  of  the  patient  to  give  a  proper  importance  to  his 
complaints,  he  is  apt  to  magnify  his  symptoms.  However,  there 
are  certain  means  of  checking  the  patient's  statements  so  that  it 
may  be  ascertained  whether  or  not  he  is  speaking  the  truth. 

FACTORS   UPON   WHICH   INTENSITY  DEPENDS 

Before  going  into  details  concerning  these  means,  we  must  first 
study  the  factors  upon  which  the  intensity  of  pain  depends.  These 
factors  are:  (1)  the  stimulus;  (2)  the  sensitiveness  of  the  pa- 
tient; (3)  the  irritability  of  the  nerves;  and  (4)  the  extent  and 
number  of  the  nerves  involved. 

The  Stimulus. — The  stimuli  may  be  of  different  degrees  and 
strength,  and  they  may  be  exerted  continuously  or  intermittently. 
A  stimulus  that  is  exerted  continuously  will  be  felt,  at  first,  as 
much  more  severe  than  one  of  equal  force  which  is  not  so  exerted. 
As  the  stimulus  continues,  the  reaction  becomes  weaker,  until  the 
perception  center  is  dulled  and  does  not  react.  Likewise,  a  con- 
stant stimulus  alternately  weak  and  strong  will  be  more  painful 
than  one  which  is  constant,  but  of  equal  force.  The  reason  for  this 
is  that  when  the  stimulus  is  constant,  either  the  conducting  or  the 
perceptive  apparatus  becomes  fatigued,  and  the  stimulus  is  not  per- 
114 


FACTORS   MODIFYING   PAIN   PRODUCTION  115 

ceived  as  acutely  as  when  intermissions  take  place,  since  during 
these  intermissions  the  nerves  have  time  to  recover  their  sensitive- 
ness. 

Sensitiveness  of  the  Patient. — Susceptibility  to  pain  varies 
among  different  individuals.  Some  react  to  a  painful  stimulus 
much  more  readily  than  do  others.  My  experience  has  shown 
that  those  of  a  thin  and  neurotic  build  suffer  much  more  severely 
than  do  the  heavier  and  more  robust.  There  seems,  also,  to  be  a 
certain  relationship  between  the  degree  of  mentality  and  suscep- 
tibility to  pain.  The  higher  the  development  and  the  more  vivid 
the  imagination,  the  greater  is  the  susceptibility.  Those  who  are 
not  particularly  affected  by  pain  or  emotion  we  call  phlegmatic. 

Centric  Increased  Irritability. — In  certain  cases  there  is  a 
change  produced  in  the  nerve  cells  themselves  which  may  be  ex- 
pressed. This  change  produces  increased  susceptibility  to  various 
stimuli,  so  that  pain  may  be  produced  by  a  minor  irritation. 

Irritability  of  the  Nerves. — The  trigeminus,  the  sciatic,  and 
the  splanchnic  nerves  are,  as  compared  with  others,  extremely  ir- 
ritable. 

Extent  and  Number  of  Nerve  Fibers  Involved. — The  severity 
of  the  pain  depends  upon  the  number  of  fibers  which  are  involved. 
The  greater  the  number  of  fibers  the  more  intense  the  pain. 

FACTORS   MODIFYING   PAIN   PRODUCTION 

The  factors  modifying  pain  production  are  psychical  and 
physical. 

Psychical  Factors. — The  psychical  factors  may  be  divided 
again  into  emotion,  consciousness,  suggestion,  diversion  of  atten- 
tion, and  expectation  of  pain. 

Emotions  greatly  modify  pain-sensation.  For  instance,  vio- 
lent anger  or  great  joy  preempts  the  sensorium  to  such  an  extent 
that  sense  perception  is  dulled  and  may  become  absolutely  nega- 
tive. Consciousness  of  course,  is  necessary  for  the  perception  of 
pain,  and  the  more  acute  the  consciousness  the  greater  the  pain. 
Those  who  are  worn  out  with  ph.ysical  work  will  ©rt^n  sv.f?cr  less 


116  THE   INTENSITY   OF  PAIN 

from  an  injury  than  their  more  vigorous  fellow-workers.  Sugges- 
tion is  also  of  considerable  importance  in  pain  phenomena.  Many 
modern  cults  have  made  capital  ou^  of  the  fact  that  pain  may 
often  be  eased  by  concentration  upon  some  other  object,  or  by  self- 
persuasion  (auto-suggestion)  that  pain  is  not  present.  Yet  this  is 
not  new,  for  physicians  have  made  use  of  this  principle  even  as 
far  back  as  the  time  of  Pharaoh.  Diversion  of  attention  is  im- 
portant, for  the  reason  that  when  a  patient's  attention  is  drawn 
to  some  object,  and  is  entirely  engrossed  with  it,  he  has  two  cen- 
ters (sensory)  which  are  active,  as  a  consequence  of  which  neither 
is  apt  to  be  as  sensitive  as  if  acting  alone. 

Physical  Factors.  — Physical  factors  influencing  pain  may  be 
divided  into  the  intrinsic  and  the  extrinsic.  Among  the  intrinsic 
factors  are  digestion,  motion,  urination,  defecation,  menstrua- 
tion, respiration,  and  position  of  the  body.  Among  the  extrinsic 
factors  are  pressure,  heat,  cold,  electricity,  and  drugs. 

Intrinsic. — Digestion,  as  a  rule,  causes  pain  only  when  dis- 
ease of  the  alimentary  tract  or  some  of  its  related  organs  is  pres- 
ent. The  severity  of  the  pain  depends  upon  the  kind  of  food 
taken,  and  the  variety  of  the  lesion.  In  all  cases  indigestible 
food  increases  the  pain.  When  the  pain  comes  on  immediately 
after  eating,  one  would  naturally  think  of  gastric  ulcer;  if  in  an 
hour  or  two,  of  duodenal  ulcer;  and  if  in  three  or  four  hours,  of 
gall-bladder  or  common  duct  disease.  Also,  at  about  the  same 
interval  pain  due  to  appendiceal  or  colonic  diseases  makes  its 
appearance,  although  that  from  colonic  disease  generally  occurs 
somewhat  later,  say  in  five  or  six  hours.  Should  the  entrance  of 
food  into  the  stomach  ease  the  pain,  carcinoma,  duodenal  ulcer,  or 
a  pure  neurosis  is  probably  present  (Schmidt).  Should  the  pain 
come  on  during  the  ingestion  of  food,  it  indicates  some  disturb- 
ance in  the  esophagus,  such  as  ulcer,  stenosis,  or  a  lesion  at  the 
cardiac  entrance  to  the  stomach,  such  as  cardiospasm. 

In  all  inflammatory  states,  when  motion  causes  pressure  to  be 
made  upon  the  inflamed  area,  pain  results.  When  a  patient  com- 
plains of  pain  upon  moving  a  part,  careful  investigation  should 
be  made  of  the  muscles,  bones,  joints,  and  nerves  composing  that 


FACTORS  MODIFYING   PAIN  PRODUCTION  117 

part.  In  connection  with  the  muscles  the  most  common  painful 
affections  are  inflammations,  as  myositis  or  abscesses.  In  some 
cases,  while  the  lesion  is  not  in  the  muscle  itself,  it  is  adjacent 
thereto,  and  contraction  of  the  muscle  will  produce  traction  and 
pressure  upon  the  inflamed  area.  Such  a  condition  is  found  fre- 
quently in  appendicitis.  The  appendix  lies  over  and  is  joined  to 
the  psoas,  so  that  each  time  the  limb  is  flexed,  and  the  psoas  con- 
tracts, pulling  and  traction  on  the  inflamed  tissues  occur,  and 
pain  is  felt.  Therefore,  whenever  pain  is  complained  of  in 
connection  with  muscular  movement,  not  only  the  muscle  but  all 
of  its  adjacent  and  related  structures  should  be  investigated. 
Should  the  muscle  prove  negative  the  bone  may  give  some  infor- 
mation as  to  the  cause  of  the  pain.  In  this  direction  the  first 
line  of  inquiry  will  be  as  to  the  condition  of  the  periosteum,  and 
if  it  is  found  to  be  healthy,  the  bone  may  be  excluded  as  a 
cause  of  pain.  After  careful  investigation  of  these  structures, 
the  joints  should  be  examined,  and  flexion  and  extension  tried. 
Especially  in  disease  of  the  articular  cartilages  pressure  made  by 
forcibly  pressing  the  two  articular  surfaces  against  each  other 
is  provocative  of  the  greatest  pain. 

Pain  may  be  caused  by  change  of  yosiiion.  This  occurs  espe- 
cially in  those  organs  which  are  held  in  position  by  "ligaments  and 
end  attachments,  such  as  the  stomach."  Here  a  change  of  posi- 
tion produces  a  disturbance  of  their  relationship  to  surrounding 
organs,  and  in  some  cases  a  derangement  of  their  functional 
econom}'.  It  may  produce,  also,  pressure  or  traction  on  an  in- 
flamed area.  All  of  these  factors  lead  to  an  increased  amount 
of  irritation  and  pain.  The  occurrence  of  a  painful  lesion  upon 
a  change  of  position  of  the  patient  indicates  a  local  disorder. 
Certain  positions  are  characteristic  of  certain  classes  of  disease 
(see  Positions  of  Pain). 

Pain  associated  with  defecation  occurs  at  the  time  of  the 
movement,  or  a  little  later.  If  it  occurs  at  the  time  of  the  move- 
ment one  would  naturally  think  of  some  lesion  involving  the 
sphincter  or  the  anus.  Of  these,  inflammation,  from  simple  in- 
filtration to  abscess  formation,  is  very  painful.     As  much  so,  or 


118  THE  INTENSITY  OF  PAIN 

even  more  painful,  is  fissure  or  ulcer  of  the  anus.  When  the 
pain  persist  for  some  time  after  defecation  an  abscess  may  be 
present.  Pain  coming  on  immediately  before  the  act  indicates 
deep-seated  ulceration,  such  as  would  occur  in  carcinoma  of  the 
rectum  (Schmidt,  p.  42).  Abdominal  pain,  the  result  of  strain- 
ing accompanying  bowel  movement,  may  indicate  some  quiescent 
inflammatory  process  in  the  appendix  or  the  gall-bladder.  By 
constipation  the  pain  of  enteroptosis,  intestinal  atony  and  neu- 
ropathic conditions  is  retarded. 

Extrinsic. — Of  the  extrinsic  physical  factors  modifying  pain, 
pressure  is  by  far  the  most  important.  In  many  instances  it  is 
the  underlying  factor  of  pain-production.  Structures  are  so  joined 
and  related  to  each  other  that  pressure  is  constantly  exerted  by  the 
one  upon  the  other,  and  any  disarrangement  of  this  adjustment 
may  cause  the  pressure  to  become  excessive,  and  result  in  pain. 

Electricity  causes  pain  by  stimulating  the  pain  receptors.  The 
pain  may  also  be  due  in  part  to  muscular  contraction  and  to  sud- 
den changes  in  the  relationships  of  the  parts,  caused  by  opening 
or  closing  of  the  circuit.  The  faradic  current  is  probably  the 
most  painful.     The  static  spark  is  also  quite  painful. 

Extremes  of  heat  and  cold  both  cause  pain,  and  the  sensations 
caused  by  excessive  degrees  of  either  are  almost  identical.  Thus 
it  is  that  one  speaks  of  the  burn  due  to  excessive  cold.  In  case  of 
pain  due  to  freezing  of  a  part  additional  pain  is  produced  by  plac- 
ing the  hand  in  hot  water,  which  is  due  to  the  dilatation  of  the 
vessels  and  engorgement  of  the  tissues  of  the  part.  This  engorge- 
ment increases  the  pressure  upon  the  pressure-pain  receptors,  and 
thus  causes  an  increase  of  pain.  Cold  acts  in  an  opposite  manner. 
It  causes  contraction  of  the  vessels  and  a  lessened  blood  supply 
in  the  part.  Metabolism  is  interfered  with,  and  toxic  products^ 
accumulate  in  the  tissues.  These  act  upon  the  sensory  receptors 
and  cause  pain  in  addition  to  that  caused  by  the  action  of  cold 
upon  the  cold  pain  receptors.  In  these  cases  the  pain  is  due  to  the 
stimulation  of  the  temperature  receptors,  plus  the  stimulation  of 
the  deep  sensibility  receptors.     In  some  cases  of  heat  pain,  for  a 

I  Toxic  products  also  In  some  cases  produce  anesthesia.      See  under  Toxemia. 


FACTORS   MODIFYING   PAIN   PRODUCTION  119 

short  time  two  different  sensations  are  felt,  one  being  that  of  heat, 
and  the  other  that  of  pain.  Then  the  sensation  of  heat  disappears 
and  only  that  of  pain  "persists.  The  only  reason  that  both  cannot 
continue  is  that  the  pain  sensation  soon  becomes  paramount,  and 
preempts  the  sensorium.  Another  argument  in  favor  of  the  sepa- 
rate origin  of  temperature  sensation  and  of  pain  sensation  from 
excessive  degrees  of  heat  or  cold  is  that  pain  may  be  present  from 
hyperstimulation  of  either,  in  the  absence  of  temperature  sense. 
That  is,  excessive  degrees  of  heat  or  cold  produce  pain,  while 
moderate  degrees  of  either  cannot  be  recognized,  or,  if  they  are, 
the  one  is  confused  with  the  other.  According  to  Trevis,  the 
temperature  sensation  in  mucous  membranes  is  much  less  than  in 
the  skin,  and  the  sensibility  diminishes  the  further  the  locality 
from  the  cutaneous  opening.  Through  inflammation  it  seems  to  be 
rendered  more  sensitive. 

Drugs  modify  pain  by  various  means.  They  usually  block 
the  carrying  power  of  the  nerves  peripherally  (morphin  or  co- 
cain)  or  centrally  (morphin  or  ether).  They  may  create  changes 
in  the  organs  in  which  pain  arises,  and  thus  cause  changes  in  the 
pain.  For  instance,  alkalies  reduce  the  acidity  of  the  stomach  and 
decrease  the  pain  caused  by  a  hyperacidity.  Mercury  and  the 
iodids  frequently  relieve  pain  due  to  syphilis.  On  the  other  hand, 
tuberculin  increases  the  pain,  if  it  is  due  to  tuberculosis  (Schmidt, 
p.  40).  Emptying  the  bowels  relieves  certain  headaches.  The 
withdrawal  of  morphin,  in  the  case  of  a  person  who  is  accustomed 
to  its  use,  very  frequently  causes  great  pain. 

Weather.— Fsan  also  seems  to  be  influenced  by  temperature 
changes,  for  it  has  been  observed  that  a  lessened  barometric  pres- 
sure causes  a  weakened  resistance  to  pain.  Evertt  (566)  found  the 
period  of  greatest  pain  to  be  from  nine  to  eleven  a.  m.  A  period  of 
less  severe  suffering  is  between  eight  and  ten  a.  m.  Barometric 
changes  influence  the  production  of  pain  more  than  the  presence 
of  storms.  Damp,  musty  weather  also  influences  pain  production 
(Head  and  Rivers,  201,  p.  54).  Evertt  believes  that  the  cause  of 
this  increase  in  pain  is  that  the  electricity  in  the  air  is  increased 
during  these  periods  of  atmospheric  unrest. 


120  THE   INTENSITY    OF   PAIN 

ESTIMATION   OF   THE   INTENSITY    OF    PAIN 

It  is  necessary,  not  only  to  know  that  a  person  has  pain,  but 
also  how  to  estimate  and  measure  its  intensity.  This  knowledge 
is  important  in  order  to  check  the  many  misunderstandings  that 
occur,  sometimes  intentionally,  sometimes  unconsciously,  between 
the  physician  and  his  patient.  It  is  also  of  value  occasionally,  in 
deciding  upon  the  progress  of  a  disease.  The  different  means  of 
measuring  the  intensity  of  pain  are:  (1)  blood-pressure  eleva- 
tion; (2)  motor  reflexes;  (3)  complaints  of  the  patient,  com- 
pared with  his  ability  to  withstand  pain;  (4)  reflex  vasomotor 
signs,  as  syncope;  (5)  dilatation  of  the  pupil;  (6)  amount  of 
morphin  necessary  to  overcome  the  pain;  (7)  appearance  of  the 
patient;  (8)  patient's  description  of  the  pain,  and  (9)  mechanical 
factors. 

Blood-pressure  Elevation. — Blood-pressure  elevation  is  an  im- 
portant means  of  estimating  the  intensity  of  a  pain.  Studies 
along  this  line  have  been  made,  particularly  in  Germany,  where 
the  question  of  simulation  is  so  important,  because  of  indus- 
trial insurance.  Curschman  (567)  found  that  in  eighteen  out  of 
twenty  people  with  normal  sensibility  the  blood  pressure  rose 
eight  or  ten  mm.  of  mercury  under  stimulation  with  a  f  aradic  cur- 
rent (on  the  upper  part  of  the  thigh).  In  the  other  two  persons 
the  rise  was  somewhat  higher  (ten  to' fifteen  mm.).  In  nine  ca'ses 
of  hysteria  and  in  five  cases  of  disease  of  the  spinal  cord,  the  pres- 
sure was  unaffected.  During  the  gastric  and  intestinal  crises  of 
tabes,  and  in  lead  colic,  a  pressure  of  170  to  210  is  common,  but 
quickly  subsides  to  normal,  115  or  120  mm.,  when  the  attack  is 
over.  In  other  painful  abdominal  affections  only  a  very  moderate 
increase  in  pressure,  ten  mm.,  occurred.  Janeway  reports  the 
following  cases:  (1)  A  woman  of  twenty-eight,  with  a  blood 
pressure  of  70-80  mm.  between  the  paroxysms  of  pain,  had  170  to 
190  mm.  in  moderate  and  240  mm.  in  very  severe  attacks.  (2) 
A  man  thirty  years  old  had  a  blood  pressure  of  65  mm.  between 
paroxysms  and  of  140  mm.  during  the  paroxysms.  The  climax. 
cf  hypertension  and  pain  seemed  to  coincide,  and  both  passed 


ESTIMATION   OF   THE  INTENSITY   OF   PAIN  121' 

away  together.  Morphin  caused  sleep  and  a  lessening  of  the  pain, 
but  no  fall  in  pressure.  Chloral  caused  a  hypotensive,  as  well  as 
an  analgesic,  effect. 

"Of  special  interest  (again  to  quote  Janeway's  words)  was  the 
alternation  of  the  abdominal  and  the  lancinating  pains.  When  the 
latter  came  on,  the  pressure  promptly  fell,  and  the  visceral  crises 
ceased.  Therefore,  Pal  assumes  that  a  spasm  of  the  splanchnic 
vessels  is  the  cause  of  pain  in  a  gastric  crisis,  and  that  the  irrita- 
tion which  causes  the  lancinating  pains  affects  depressor  fibers 
in  the  posterior  roots,  and  the  stimulus  is  sufficient  to  interrupt 
or  cut  short  an  abdominal  crisis"  (Janeway,  568,  p.  247). 

In  this  connection  it  is  of  value  to  know  that  an  arterioscler- 
otic condition  of  the  abdominal  arteries  will  at  times,  when  the 
pressure  is  high,  cause  a  dull,  aching  pain  in  the  abdomen.  This 
increase  in  the  blood  pressure  is  due  to  the  stimulation  of  the  vaso- 
motor nerves  (the  vasoconstrictor  part),  and  is  produced  princi- 
pally in  the  splanchnic  area.  During  labor  pains,  also,  the  blood 
pressure  is  raised.  Coincident  with  each  pain  it  becomes  higher, 
and  varies  directly  as  the  pain.  As  labor  continues  there  is  a 
constant  increase  in  pressure  until  the  child  is  expelled,  when 
there  is  a  drop  to  a  point  slightly  below  normal.  This  increase  of 
blood  pressure  is  not  due  to  the  psychic  influence  of  pain,  for  it  is 
present  even  when  the  patient  is  unconscious  from  the  administra- 
tion of  an  anesthetic.  It  may  be  due  to  the  following  causes: 
(a)  uterine  contractions;  (b)  muscular  contractions  of  the  abdomi- 
nal wall,  causing  an  emptying  of  the  splanchnics  and  a  consequent 
increase  of  the  peripheral  pressure ;  (c)  excitement  when  the 
patient  is  conscious.  Worry  may  also  have  influence.  It  seems 
hardly  reasonable  to  suppose  that  the  small  increase  in  the  quan- 
tity of  blood  thrown  into  circulation  at  each  contraction  of  the 
uterus  would  be  sufficient  (when  we  consider  the  great  adapta- 
bility of  the  circulatory  system  to  accommodate  great  or  sudden 
increases  in  the  amount  of  circulation  fluid)  to  cause  any  appre- 
ciable increase  in  the  systolic  blood  pressure ;  though  the  asso- 
ciated contraction  of  the  abdominal  muscles,  and,  in  fact,  of 
nearly  all  of  the  musculature  of  the  body,  it  is  reasonable  to 


122  THE   INTENSITY    OF   PAIN  ' 

suppose,  will  produce  a  great  elevation  of  blood  pressure.  We 
must  bear  in  mind,  also,  the  fine  supply  of  sympathetic  nerve 
fibers  to  the  uterus  and  adnexa.  After  all,  the  increased  vascular 
tone  is,  in  all  probability,  due  to  this  elaborate  nerve  supply  and 
its  irritation. 

Motor  Reflexes. — The  reflexes  produced  by  pain  are  protective 
in  their  tendency,  in  that  they  are  a  means  of  defense  instituted 
by  nature  against  injury.  In  every  instance,  if  possible,  they 
tend  to  remove  the  organism  from  the  source  of  danger.  They 
are  very  active  and  are  constantly  exerted.  For  instance,  when 
the  hand  comes  in  contact  with  a  heated  object,  it  is  immediately 
drawn  away  by  a  quick,  automatic  muscular  movement,  even  be- 
fore the  individual  becomes  aware  of  the  contact.  In  sleep  many 
reflexes  are  active,  and  in  some  diseases  of  the  cord  (transverse 
myelitis)  they  may  be  present  even  when  pain  sensation  is  absent. 
Even  in  light  anesthesia,  this  reflex-protective  action  is  present, 
as  is  seen  in  abdominal  operations  when  the  parietal  peritoneum 
is  somewhat  roughly  handled.  Although  sensation  is  not  present, 
the  reflexes  are,  and,  acting  immediately,  produce  such  a  sudden, 
strong  contraction  of  the  abdominal  muscles,  that  it  is  almost  im- 
possible for  the  surgeon  to  do  his  work.  The  defensive  power  of 
the  reflexes  is  best  exemplified  in  consciousness  when  the  patient  is 
under  the  influence  of  pain.  The  centers  for  voluntary  muscles 
are  thrown  into  activity,  so  that  the  organs,  the  seat  of  deleterious 
changes,  may  be  protected  from  injury.  Every  physician  is  aware 
of  the  rigid  contraction  of  the  abdominal  muscles  in  pelvic  or  peri- 
toneal disease,  and  of  the  extent  to  which  the  administration  of 
an  anesthetic  simplifies  and  renders  easy  a  manual  examination. 
Can  anyone  doubt  that  the  higher  automatisms,  with  appreciation 
of  pain,  are  active  in  causing  this  rigidity?  Almost  innumer- 
able examples  of  the  same  kind  might  be  cited,  for  instance,  the 
contraction  of  the  muscles  surrounding  a  joint,  and  its  consequent 
fixation,  in  those  cases  in  which  articular  inflammatory  states  are 
present,  or  the  rigidity  of  the  head  in  disease  of  the  soft  struc- 
tures at  the  base  of  the  skull  in  meningitis,  etc. 

In  view  of  the  universality  of  these  defensive  reflexes,  it  is 


ESTIMATION   OF   THE  INTENSITY   OF   PAIN  123 

fitting  that  we  should  be  a  little  curious  as  to  the  reason  for  their 
presence.  We  know  that  nature  is  always  purposeful.  Every 
act  is  conservative,  and  we  may  be  sure  that  when  pain,  with 
its  attending  reflexes,  is  present,  there  is  a  good  reason  for  its 
appearance.  This  reason  is  protection  against  further  injury. 
For  this  purpose  are  called  into  play  the  only  reflex  organs  in 
the  body  capable  of  resistance,  namely,  the  muscles.  As  a  result 
of  their  stimulation  and  consequent  contraction  either  rigidity  or 
motion,  or  both,  follow.  Rigidity  is  best  seen  in  the  cases  of 
abdominal  diseases  above  mentioned ;  motion  is  best  illustrated 
by  the  quick  withdrawal  of  the  hand  from  a  source  of  injury. 

Two  of  the  special  senses,  taste  and  smell,  owing  to  their  func- 
tions, have  developed  a  special  sensation  which  is  termed  nausea. 
It  is  of  a  disagreeable,  sickening  nature;  and  finally,  if  sufii- 
ciently  prolonged,  causes  a  protective  reflex  action  in  the 
form  of  vomiting.  This  reflex,  as  one  would  judge  from  its  inti- 
mate dependence  upon  the  sympathetic  system,  is  practically  an 
involuntary  act,  though  sometimes  it  can  be  produced  by  conjuring 
up  in  the  mind  pictures  of  disagreeable  or  disgusting  objects. 

Hearing,  also,  is  somewhat  different  from  the  other  senses. 
Here  an  excessive  stimulant  gives  rise  to  a  sensation,  which,  if  it 
cannot  be  accurately  classified  as  pain,  is  closely  akin  to  it,  be- 
cause of  its  intensely  disagreeable  nature.  When  this  sensation 
is  present,  protection  from  the  causative  agents  (noises,  etc.)  is 
sought  by  placing  the  hands  over  the  ears,  so  that  the  distressing 
sounds  may  not  enter. 

All  of  these  reflexes  are  accompanied  by  certain  well-marked 
and  clearly  defined  changes  in  other  systems,  as  the  circulatory, 
digestive  and  pulmonary  systems. 

Complaints  of  Patient  Compared  with  His  Susceptibility. — 
A  comi^arison  of  the  comj^laints  of  the  patient  with  his  ability  to 
withstand  pain  often  gives  an  indication  of  the  severity  of  the 
pain.  This  ability  varies  in  different  people.  Some,  especially 
those  of  a  phleg-matic  temperament,  seem  to  be  capable  of  bearing 
pain  of  much  greater  intensity  than  those  of  a  nervous,  active 
nature.     Blondes,  also,  seem  to  be  more  sensitive  than  brunettes. 


124  THE   INTENSITY    OF   PAIN 

Personal  idiosyncrasies,  however,  are  of  great  value  in  estimating 
the  severity  of  pain. 

To  determine  the  sensibility  of  the  patient,  the  skin  on  an  un- 
affected part  of  the  body  should  be  pinched  between  the  fingers. 
When  the  abdomen  is  not  affected,  it  is  best,  because  of  its  great 
sensitiveness,  to  use  it  as  a  control.  By  the  response  to  various 
degrees  of  pressure,  an  estimation  can  often  be  made  of  the 
susceptibility  of  the  patient. 

Vasomotor  Signs.' — Vasomotor  signs,  as  pallor  and  syncope, 
often  give  an  indication  of  the  severity  of  the  pain.  These 
changes  are  due  to  a  reaction  of  the  pain  stimuli  upon  the  vaso- 
motor system,  and  it  is  necessary  to  inquire  into  their  cause. 
The  vasomotor  system  consists  of  centers  to  Avliich  two  sets  of 
fibers  are  connected,  namely,  the  inhibitory  fibers  and  the  con- 
strictor fibers.  The  inhibitory  fibers  convey  impulses  which  hin- 
der the  contraction,  and  the  constrictor  fibers  convey  impulses 
which  stimulate  the  contraction  of  the  muscular  coat  of  the  blood- 
vessels. It  is  very  difficult  to  say  in  what  way  mental  states  have 
an  action  on  the  physical  processes  of  the  body;  but  that  they 
have  is  evident,  and  that  the  action  is  a  powerful  one  can  be 
seen  from  the  persistence  of  the  induced  physical  changes.  How 
the  vasomotors  are  influenced  it  is  very  difficult  to  say.  Yet  we 
know  that  they  may  be  influenced  by  many  mental  processes. 
For  instance,  pallor  is  induced  by  fear,  fatigue,  nausea,  or  severe 
pain.  Redness  is  induced,  in  the  process  called  blushing,  either 
by  a  stimulation  of  the  vasomotor  inhibitory  fibers  or  by  a 
paralysis  of  the  contracting  fibers,  producing  a  paralysis  and 
dilatation  of  the  blood-vessels  of  the  face  and  neck.  The  vaso- 
motor fibers  pass  up  the  cord  in  the  lateral  tracts,  and  pain  sen- 
sation is  also  conveyed  by  the  lateral  tracts;  so  it  can  easily  be 
seen  how  any  change  in  the  fibers  conveying  pain  sensation  would 
react  on  the  vasomotor  fibers  and  produce  changes  in  them. 

Pallor  and  syncope  may  be  the  indication  of  shock  due  to 
intense  irritation  of  the  sensory  terminal  filaments.  According 
to  Henderson,  this  shock  is  the  result  of  the  rapid  resj^iration  al- 
ways induced  by  peripheral  sensory  irritation.    In  his  experiments' 


ESTIMATION   OF   THE   INTENSITY   OF   PAIN  125 

consciousness  was  abolished  by  the  use  of  ether  and  morphin,  so 
that  the  results  were  not  due  to  consciousness  of  suffering,  but  to 
nerve  irritation.  It  seems  that  consciousness  of  suffering  is  a 
mere  accompaniment  and  not  a  causal  element  in  the  production 
of  shock,  which  is  of  a  reflex  nature.  Among  other  signs  of  shock 
are  rapid  and  feeble  pulse,  vomiting,  drawn,  anxious  features, 
and  excessive  perspiration.  The  susceptibility  to  shock  varies. 
In  those  of  a  well-marked  nervous  temperament  shock  from  a 
small  injury  is  greater  than  in  those  of  a  more  phlegmatic  nature. 
Some  women  are  almost  prostrated  with  the  pain  of  menstruation, 
while  others  hardly  seem  to  mind  it.  The  same  may  be  said  of  the 
parturient  state  (Lazarus-Barlow,  571,  p.  478). 

Dilatation  of  the  Pupil. — Dilatation  of  the  pupil  is  produced 
by  irritation  of  the  sympathetic  nervous  system,  particularly  in 
the  splanchnic  area.  This  reaction  can  be  made  use  of  when 
estimating  the  tenderness  of  a  part.  Yet,  in  using  it,  one  must 
not  forget  that  pressure  alone  will  produce  dilatation  of  the 
pupil,  especially  when  exerted  on  the  abdomen,  and  that  dilata- 
tion may  also  be  produced  by  stroking  or  pinching  the  neck 
(Schmidt).  Some  idea  of  the  dilatation  due  to  pressure  alone 
should  be  gained  by  stimulation  of  a  non-painful  part.  Then,  with 
this  as  a  standard,  an  estimation  of  the  dilatation  due  to  pain  can 
be  made.  This  method  is  not  available  after  the  use  of  drugs,  such 
as  morphin,  cocain,  and  belladonna,  which  have  an  action  on  the 
pupil. 

Amount  of  Morphin  Necessary  to  Overcome  Pain. — The 
amount  of  morphin  necessary  to  ease  pain  is  a  good  indication  of 
its  severity.  Colic  requires  more  morphin  than  many  other  vari- 
eties of  pain.  This  is  especially  true  of  gall-duct  or  pancreatic 
duct  colic,  and  renal  colic  is  especially  noted  for  its  persistence  and 
severity. 

Appearance  of  Patient. ^ — The  appearance  of  the  patient  fre- 
quently is  a  reliable  index  of  the  variety  and  severity  of  his  pain. 
As  a  rule,  pain  of  great  severity  produces  a  cessation  of  muscular 
movement.  To  this  there  is  one  great  exception,  namely,  the  pain 
of  colic.     Here,  whether  the  colic  is  of  urinary,  biliary  or  intesti- 


126 


THE   INTENSITY   OF   PAIN 


nal  origin,  the  patient  writhes,  squirms  and  assumes  all  conceiv- 
able positions,  at  the  same  time  crying  out  or  moaning.  These 
attacks  come  in  paroxysms,  a  period  of  quiet  following  each 
attack.  In  colic,  also,  the  patient  presses  with  his  hands,  or  with 
a  bolster,  upon  the  abdomen,  and  frequently  lies  with  his  limbs 
drawn  up  (see  Figs.  87,  88).  Here  the  tendency  to  exert  pres- 
sure is  seen  in  the  characteristic  way  in  which  the  hands  are  joined, 
the  fingers  being  interlocked  so  that  greater  pressure  may  be  ex- 
erted. 

This  picture  is  the  exact  opposite  to  that  seen  in  peritonitis, 
where  the  patient  is  absolutely  quiet,  lying  flat  upon  his  back 


Fig.  37. — Hand  Pressing  on  the  Abdomen  is  Very  Characteristic  of 
Colic,  i.  e.,  of  the  Uterus  or  Intestine. 

1.  Area  of  referred  pain  in  phlebitis  (femoral).      Also  area  of  distribution 
of  ant.  crural  and  area  of  pain  reference  in  crural  neural G;ia. 

2.  LocaUzed  tenderness  in  phlebitis. 

3.  Phlebitis  (femoral  vein). 
Hip  joint  disease. 
Psoas  abscess  (low). 

4.  Ovary  infianunation.   ) 

Salpingitis.  r  It  is  more  characteristic  for  patient  in  these  con- 

5.  Appendicitis.  )        ditions  to  he  on  back. 


with  his  limbs  drawn  up  and  hands  frequently  placed  lightly 
upon  his  abdomen.  He  is  very  attentive,  and  is  ever  ready  to 
ward  off  any  touch  or  pressure  with  the  other  hand  (see  Fig.  86). 
To  this  posture  the  term  "abdominal  protective  position"  has  been 
given.  Other  characteristic  postures  are  illustrated  in  Figs.  37, 
38.  Headaches  also  give  rise  to  characteristic  postures,  as  may  be 
seen  in  the  Figs.  Q6,  67,  68.      . 


ESTIMATION   OF    THE   INTENSITY   OF   PAIN 


127 


In  pleurisy  or  intercostal  neuralgia  the  patient  assumes  a  rigid 
chest  position,  and,  on  close  examination,  it  is  noticed  that  the 
thoracic  respiration  is  hindered.  This  is  exactly  opposite  to  what 
happens  in  abdominal  inflammatory  disease,  in  which  the  breath- 
ing is  of  the  thoracic  type, 
abdominal  breathing  hav- 
ing ceased  entirely. 

When  the  patient  moves 
with  considerable  pain  and 
refuses  to  stand  on  a  limb, 
and  holds  the  joint  in  a 
flexed  position,  inflamma- 
tory disease  of  the  joint 
should  be  suspected.  The 
position  assumed  in  dis- 
tention of  the  vesical  blad- 
der is  one  in  which  the  pa- 
tient inclines  slightLj  for- 
ward, his  back  straight  and 
rigid,  pressing  both  hands, 
which  are  interlockea, 
over  the  lower  segment  of 
the  abdomen.  Tumor  or 
aneurysm  is  indicated  as  a 
rule  by  pressure  over  the 
diseased  area.  In  men- 
ingitis the  patient  remains 
rigid  because  of  the  pain 
(Eyder,  35). 

The  facial  expression 
also  is  frequently  a  reliable  index  of  the  severity  of  pain.  One 
expression  which  is  indicative  of  the  most  severe  pain  is 
the  so-called  Hippocratic  facies,  in  which  the  brow  is  con- 
tracted, the  lips  drawn  back,  the  eyes  fixed  and  the  entire 
attention  focused  upon  some  intrinsic  phenomenon.  This  is  the 
characteristic  facies  of  peritonitis,  and  when  present  is  of  serious 


Fig.  38. — Position  Assumed  in  Uterine 
Colic,  Intestinal  Colic,  and  Dis- 
tended Urinary  Bladder. 


128 


THE   INTENSITY    OF   PAIN 


import.  In  some  i^aticnts,  especially  among  those  who  have 
trained  their  features  to  express  emotion,  simulation  is  often  prac- 
ticed ;  yet,  nnder  close  observation,  one  will  notice,  at  times,  some 

relaxation  or  change  in  ex- 
pression, especially  when 
the  patient  thinks  he  is  not 
being  watched. 

Gestures  indicative  of 
pain  are  principally  those 
in  which  the  patient  tries  to 
ward  off  an  imaginary  or  an 
actnal  injury.  Motion  as 
an  indication  of  the  severity 
of  pain  is  of  some  value, 
but  is  chiefly  of  use  in 
pointing  to  the  structures 
which  are  involved.  As  a 
rule,  all  pains  of  moderate 
severity  cause  a  loss  of 
function  of  the  part,  and  the 
patient  usually  lies  quietly 
in  bed,  attentive  but  mo- 
tionless, except  in  cases  of 
abdominal  colic,  in  which 
each  paroxysm  is  indicated 
by  sudden  and  explosive 
movements.  In  children, 
according  to  Eustace  Smith,  pain  in  the  head  is  indicated  by  a  con- 
traction of  the  brow;  in  the  chest  by  a  sharpness  of  the  nostrils, 
and  in  the  abdomen  by  a  drawing  in  of  the  upper  lip  (Musser, 
p.  79). 

Patient's  Description. — A  patient's  description  of  his  suffer- 
ings is  not  of  much  practical  assistance  in  deciding  upon  the 
severity  of  a  pain.  His  descriptive  ability,  powers  of  imagination, 
and  vocabulary  cause  it  to  vary  greatly.  One  factor  of  im- 
portance is  the  persistence  with  which  the  attention  of  the  patient 


Fig.  39. — Lacing  Shoe  Posture. 
In  lumbago,  spinal  caries,  hip  joint  dis- 
ease, sciatica,  appendicitis  and  pelvic 
peritonitis,  pain  is  experienced  on  the 
patient  assuming  this  position. 


ESTIMATION    OF    THE   INTENSITY   OF   PAIN 


129 


is  devoted  to  the  pain,  to  the  exclusion  of  other  topics.  Should 
he  be  consistent,  and  persist  in  his  statements  of  its  character  and 
severity,  and  should  his  attention  be  not  easily  dra^^Ti  away  or 


Fig.  40. — Pain  on  Hyperextension 
OF  THE  Body. 

Hyperextension  of  the  body  produces 
pain  in  inflammation  of  the  ab- 
dominal viscera,  adhesions,  peri- 
tonitis, etc. 

occupied  to  the  exclusion  of  the 
pain,  it  may  be  concluded  that  a 
pain  of  considerable  intensity  is 
present. 

Mechanical  Factors. — Pinching, 
chanical  factors  which  are  of  slight 
gree  of  pain  or  tenderness.     These 


Fig.  41. — Pain  on  Going  Up- 
stairs. 

When,  on  going  upstairs,  pain  is 
present  in  the  right  hmb,  it  in- 
dicates appendiceal  abscess  or 
pehdc  inflammation,  and  is 
due  to  the  tension  of  the 
psoas  muscle  producing  pres- 
sure or  traction  on  the  in- 
flamed area.  The  pain  is 
greatest  at  the  moment  of 
raising  the  foot  off  the  ground 

stroking,  pressing  are  me- 
value  in  determining  the  de- 
are  of  little  value  because  of 


(14, 

.1) 

(13, 

.9) 

(13 

— 

-12, 

.5) 

(11. 

,5— 

-12, 

.2) 

130  THE   INTENSITY   OF   PAIN 

the  variations,  both  of  pressure  and  of  the  resistance  of  the 
patient.  The  best  mechanical  aids  are  electricity,  the  von  Frey 
hairs,  algometers,  and  needles. 

In  testing  pain  by  means  of  electricity,  two  electrodes  are 
used.  They  should  be  about  the  size  of  a  knitting  needle,  and  are 
placed  from  one  to  two  cm.  apart.  In  the  following  table,  taken 
from  Bernhardt,  the  figures  showing  the  distances  of  the  cylinders 
of  the  induction  apparatus  represent  the  minima  of  sensation,  and 
the  figures  in  parentheses  represent  the  minima  of  pain  in  a 
healthy  person: 

Tip  of  the  tongue 17.5 

Palate 16.7 

Tip   of   the   nose,    eyelids,    back    of 

tongue,  gums,  lips 14 . 8 — 14 . 4 

Acromion,  sternum,  nape  of  neck.  .13.7 — 13 
Back  of  the  arm,  buttocks,  occiput, 

loin,  neck,  forearm,  vertex,  coccyx, 

thigh,  back  of  the  first  phalanx, 

back  of  the  foot 12.8—12  (12     —9.2) 

Back  of  the  second  phalanx,  back  of 

the  metacarpal  bone,  back  of  the 

hand,  leg,  distal  phalanx,  knee  ...11. 7 — 1 1.3      ( 10 . 2 —  8.7) 
Palmar   aspect   of   the   head   of  the 

metacarpal  bone,   tip   of   the  toe, 

palm  of  the  hand,  palmar  aspect  of 

second  phalanx,   hypothenar   emi- 
nence, plantar  aspect  of  the  first 

metatarsal  bone 10 . 9—10 .2      (8     —  4     ) 

These  tables  are  of  value  in  that  they  enable  one  to  compare 
the  relative  sensibility  of  the  different  areas.  Any  decrease  in 
the  distance  of  the  cylinders  would  indicate,  of  course,  an  increase 
in  the  sensitiveness  of  the  part. 

Von  Frey's  hairs,  also  used  in  the  estimation  of  sensibility, 
are  hairs  which    have  been  so  selected  that  they  bend  at  different 


ESTIMATION   OF   THE   INTENSITY   OF   PAIN  131 

pressures.  They  are  fastened  to  a  small  wooden  rod  at  right 
angles.  Previous  to  use,  the  weight  necessary  to  cause  them  to 
bend  is  ascertained. 

In  Head  and  Thompson's  experiments,  hairs  sent  by  von 
Frey  were  used.  No.  8  would  bend  at  830  mgms.  pressure;  No. 
5  would  bend  at  360  mgms.  pressure;  No.  4  would  bend  at  230 
mgms.  pressure;  and  No.  2  would  bend  at  100  mgms.  pressure. 
In  the  intervals  between  use,  they  should  be  kept  in  a  box,  with 
the  rods  supported  in  such  a  manner  that  the  hairs  do  not  come 
in  contact  with  anything  (Head  and  Thompson,  206,  p.  542). 

Algometers  have  been  described  by  Head  and  others.  A 
pointed  instrument  (as  a  needle)  is  made  to  press  against  the  skin, 
and  the  amount  of  pressure  is  indicated  by  a  scale  which  is 
attached  to  a  resisting  spring.  This  is  the  manner  in  which  most 
of  these  instruments  work.  They  are  of  considerable  value,  but 
are  not  yet  in  general  use. 

Needles  and  pins  are  also  employed  in  estimating  sensibility, 
but  their  use  involves  several  drawbacks.  First,  the  pressure 
exerted  by  them  is  variable  and  cannot  be  controlled.  Second, 
the  sense  of  touch  is  apt  to  be  confused  with  the  feeling  of  pain. 
To  avoid  the  latter,  it  is  well  to  precede  the  pin  with  the  tip  of 
the  finger,  so  that  touch  may  be  felt  first,  and  later  hyperalgesia, 
if  the  sensibility  is  increased. 

In  making  a  thorough  sensory  examination  according  to  Head's 
methods  the  following  rules  should  be  observed :  Have  the  patient 
in  an  easy  position  and  see  that  he  is  without  physical  discomfort, 
i.e.,  that  the  bladder  and  rectum  are  empty,  and  that  he  is  neither 
hungry  nor  thirsty.  The  time  of  day  best  suited  to  the  examina- 
tion is  morning,  when  the  patient  has  not  entered  upon  the  work 
and  worry  of  the  day.  Weather  conditions,  also,  are  of  some  im- 
portance. A  bright,  sunshiny  day  will  bring  more  uniform  and 
reliable  results  than  an  examination  upon  a  dismal  day.  The 
surroundings  must  also  be  propitious.  The  room  must  be  quiet, 
and  no  loud  noises  or  talking  should  be  permitted  in  the  immediate 
vicinity.  Above  all,  in  testing  the  sensibility  of  a  part,  screen  it 
from  the  observation  of  the  patient.    At  the  time  of  the  examina- 


132  THE   INTENSITY    OF   PAlN 

tion  the  external  temperature  should  be  warm,  for  anything  which 
produces  goose-flesh  detracts  from  the  value  of  the  results. 

During  an  examination  for  sensibility  both  sides  of  the  body 
should  be  compared.  If  a  certain  organ  has  been  decided  upon  as 
the  cause  of  the  pain  phenomenon  it  is  necessary,  in  order  to  be 
sure  that  the  decision  is  accurate,  to  reproduce  the  pain  by  trac- 
tion, pressure  or  manipulation  of  the  organ.  Should  the  proper 
organ  be  engaged,  a  reproduction  of  the  pain  will  result.  Unless 
this  can  be  done,  and  in  the  absence  of  definite  pathology,  it  is 
not  wise  to  make  too  positive  a  diagnosis.  On  forming  a  conclu- 
sion, one  should  not  forget  that  the  ventral  aspect  is  less  sensitive 
than  the  lateral  aspect,  and  the  lateral  aspect  less  sensitive  than 
the  dorsal  aspect  of  the  body. 

The  sensations  allied  to  pain  having  their  basic  principles  in 
touch  sensation  are:  (1)  pleasant  sensations;  (2)  agreeable  sen- 
sations; (3)  normal  quiescent  states ;  (4)  disagreeable  sensations ; 
(5)  pain  sensations.  At  one  end  of  the  series  we  have  pleasure, 
and  at  the  other  pain,  while  between  the  two  we  have  all  degrees 
of  pleasant  and  unpleasant  sensations.  As  the  sensation  becomes 
exaggerated  at  either  end,  we  have  a  condition  of  unendurable- 
ness,  for  intense  pleasure  is  just  as  unendurable  as  intense  pain, 
and  both  manifest  their  intensity  by  promptly  causing  uncon- 
sciousness, from  which  the  patient  awakes,  generally  after  the 
passing  or  subsidence  of  the  causative  sensation.  Sometimes,  fol- 
lowing unconsciousness  from  pain,  the  joatient  awakes,  and,  the 
pain  being  present,  may  become  unconscious  again.  This  pro- 
cedure may  be  repeated  many  times,  until  finally  the  pain-per- 
ceptive centers  become  fatigued  or  the  pain  disappears. 

CONDITIONS    ASSOCIATED    WITH    SEVERE    PAIN 

Associated  with  severe  pain  are  certain  symptoms  which 
indicate  to  us  the  vast  influence  which  a  severe  subjective  con- 
scious irritation  may  produce  upon  the  physical  entity.  With 
extremely  severe  jDain  there  are  often  symptoms  of  collapse,  such 
as  cold  sweats,  weak  pulse,  and  an  anxious  look.     These  are  prac- 


CONDITIONS    ASSOCIATED    WITH    SEVERE    PAIN      133 

tically  the  same  phenomena  as  those  which  accompany  any  great 
emotion,  such  as  fear,  in  which,  owing  to  the  induced  fright,  a 
vasomotor  collapse  takes  place,  the  patient  faints  and  is  cold  and 
clammy,  with  weak  and  very  often  rapid  pulse.  Happiness  is 
also  potent  to  cause  somewhat  the  same  condition,  for  we  all  know 
of  the  state  of  a  man  fainting  from  joy.  In  fact,  in  any  great 
emotional  exaltation  a  temporary  loss  of  consciousness  may  occur, 
as  in  the  sexual  act,  where  in  some  cases  the  irritation  to  the 
glans  or  clitoris  may  produce  such  a  succession  of  impulses  that 
the  receptive  centers  are  overcome  from  the  unaccustomed  fre- 
quency and  a  temjDorary  loss  of  consciousness  results.  The  cause 
of  this  unconsciousness  may  be  that  the  stimuli  which  are  trans- 
mitted to  the  refraction  center  are  referred  to  the  periphery,  and 
cause  a  vasomotor  paresis  which  gives  rise  to  lessened  circulation 
in  the  brain. ^  As  soon  as  unconsciousness  occurs,  the  sensory  per- 
ception is  lost  and  the  peripheral  impulses  to  the  vasomotors  cease. 
The  patient  now  regains  consciousness,  and  is  able  again  to  per- 
ceive the  exaggerated  impulses  (pain),  whereupon  he  promptly 
relapses  into  unconsciousness.  Thus  an  almost  endless  cycle  is 
formed.  The  same  phenomena  occur  in  the  case  of  extreme  fear. 
Cases  are  quite  common  in  which  persons,  who  have  become  un- 
conscious at  the  sight  of  some  grewsome  object,  are,  on  recovering, 
rendered  unconscious  a  second  time  at  the  sight  of  the  same 
object. 

It  is  amazing  how  much  one  can  suffer  and  still  show  no  signs 
of  it  by  physical  deterioration.  It  is  certain  that  every  practi- 
tioner has  seen  sufferers  from  the  most  severe  and  constant  neural- 
gias who  are  robust,  and  otherwise  seem  to  be  in  perfect  health. 

'According  to  Gowers  ("Clinical  Lectures,"  third  series,  p.  7),  sudden, 
intense  pain,  especially  if  felt  in  the  abdomen  or  in  the  vicinity  of  the  heart, 
may  produce  unconsciousness.  The  mechanism  is  supposed  to  be  a  direct  action 
on  the  centers  of  the  vagus,  but  syncope  (unconsciousness)  is  only  known  to 
result  if  the  pain  is  perceived.  In  man  a  cause  of  pain  a  lequate  to  produce 
syncope,  while  the  patient  is  under  the  influence  of  an  anesthetic,  has  not  been 
known.  Hence,  it  seems  doubtful  whether  the  effect  is  due  to  a  direct  action 
on  the  vagal  center.  The  facts  suggest  that  it  may  be  the  result  of  a  profound 
influence  on  the  sensory  regions  of  the  cortex,  focused  on  the  cardiac  center  in 
the  medulla. 


134  THE   INTENSITY    OF   PAIN 

After  long  periods  the  sufferer  seems  to  acquire  a  tolerance  for 
pain,  so  that  he  can,  with  a  minimum  of  discomfort,  withstand 
very  severe  attacks.  On  the  other  hand,  all  have  seen  cases  in 
which  the  constant,  steady  and  increasing  pains  of  tubercular 
disease,  trigeminal  neuralgias,  etc.,  have  completely  exhausted 
the  patient,  so  that  he  has  become  thin^  haggard,  careworn  and 
prematurely  gray.  In  many  cases  worry  and  mental  anxiety  seem 
to  have  as  much  to  do  with  the  deterioration  in  physical  charac- 
teristics of  the  patient  as  does  the  original  pain.  While  the  pain 
may  not  produce  any  apparent  physical  disturbance,  the  mental 
disturbances  are  manifold  and  remain  more  or  less  persistent  even 
after  the  pain  has  entirely  ceased.  These  mental  changes  are 
shown  in  irritability  of  temper,  neurasthenia,  etc. 

Respiratory  System. — During  severe  pain  the  respiration,  as 
a  rule,  is  increased,  and  at  the  same  time  becomes  very  shallow. 
If  the  pain  is  due  to  inflammatory  lesions  in  the  abdomen,  the 
breathing  is  of  the  costal  type,  while  if  it  is  due  to  disease  of  the 
thorax,  the  breathing  is  principally  abdominal  in  character,  and 
the  chest  is  fixed  as  though  it  were  in  splints.  These  conditions 
exist  even  when  the  patient  is  unconscious,  showing  that  they  are 
reflex  acts  and  not  in  any  way  the  result  of  inhibitory  voluntary 
action. 

Circulation. — An  acute  pain  is  almost  always  associated  with 
an  increase  of  the  pulse  rate,  while  a  chronic  pain  is  not  so  fre- 
quently associated  with  rapidity  of  the  pulse. 

Loss  of  Equilibrium.  — Pain  may  be  so  severe  tliat  a  loss  of 
equilibrium  may  result,  as  in  the  case  reported  by  Erdman  (Medi- 
cal Record,  1906,  Vol.  G9,  p.  94),  of  a  girl  thirty-two  years  old, 
who,  while  at  Mass,  was  taken  with  sudden,  excruciating  pain  in 
the  abdomen.  Although  she  fell,  she  did  not  become  unconscious. 
This  loss  of  equilibrium  may  have  been  due  to  the  fact  that  the 
stimulus  produced  by  the  pain  was  so  great  that  it  monopolized 
the  entire  sensorium,  so  that  the  equilibrizing  perceptions  from  the 
sight,  the  aural,  and  the  remaining  peripheral  senses  were  not 
perceived. 

Trophic  Changes. — Certain    disturbances    in    muscles,    joints 


METHOD    OF   RECORDING   PAIN  135 

and  bones  may  be  associated  with  pain.  These  disturbances  are 
either  (1)  functional  or  (2)  metabolic. 

Both  result  in  atrophy;  the  first  the  so-called  atrophy  of  dis- 
use, which  results  from  inactivity  caused  by  the  pain,  and  the 
other  an  atrophy  due  to  lack  of  metabolic  interchange  in  the  cells 
of  the  part.  This  metabolic  disturbance  may  be  in  the  nature 
of  a  lack  of  constructive  power,  or  an  increase  of  destructive 
change.  In  either  case,  the  final  result  is  a  wasting  and  a  diminu- 
tion in  the  power  of  the  muscle. 

Preprotective  Functions. — Associated  with  pain  is  what  may 
be  called  the  preprotective  function,  as  exemplified  in  stom- 
ach disease,  when  the  skin  over  the  epigastrium,  as  well  as  the 
upper  segment  of  the  rectus  abdominus,  becomes  somewhat  tender. 
At  the  same  time  the  rectus  is  in  a  state  of  partial  contraction,  and 
acts  as  a  g-uardian,  even  before  danger  threatens.  But  as  soon  as 
pressure  is  exerted  upon  it  the  muscle  hardens,  and  the  pain,  which 
may  have  been  light  before,  now  becomes  acute.  This  illustrates 
how  well  designed  is  the  protection  of  the  viscera,  for  if  the  stom- 
ach itself  were  sensitive  violence  would  reach  and  injure  it  before 
pain  could  be  experienced;  but  by  the  interposition  of  sensitive 
structures,  which  are  coupled  to  a  powerful  muscular  reflex  exter- 
nal to  the  stomach,  the  diseased  organ  is  effectually  guarded 
against  external  violence. 

Elevation  of  Temperature. — There  is  no  doubt  that  elevation 
of  temj)erature  is  frequently  produced  by  pain.  There  also  is  a 
close  relationship  between  the  conducting  paths  for  pain  and  for 
those  of  the  special  senses,  for  hemianesthesia  is  sometimes  ac- 
companied by  impairment  of  the  senses  of  smell,  taste,  and  hear- 
ing, and  amblyopia  is  sometimes  associated  with  concentric  con- 
traction of  the  visual  field  on  the  same  side  of  the  body. 

METHOD   OF   RECORDING   PAIN 

For  a  thorough  and  productive  study  of  pain'  it  is  necessary 
that  some  reliable  and  simple  means  of  recording  pain  phenomena 
should  be   found.      This   condition   seemingly  has  been  met  by 


136 


THE    INTENSITY    OF    PAIN 


Harris  (8-i),  whose  method  is  one  of  the  best,  and,  at  the  same 
time,  the  simplest  that  has  so  far  been  devised. 

In  his  marking  code,  four  primary  characters  are  used:  (1) 
a  simple,  unbroken  line;  (2)  a  broken  line,  or  dashes;  (3)  a  dot; 
and    (4)    a    dot   and   dash.      After   the   fourth   marking   Arabic 


0  I  •  i 


o 


•       7 


-^      a. 


1     a 


yr      —\n 


•  IS 

>  • 

IS       • 

•  «  • 


12 


\ "  J  { '• ; 


CHART   B 


Fig.  42. — Marking  Code  of  Dr.  Harris. 


numerals  are  used  to  indicate  areas,  centers,  and  radiations  of 
pain,  the  numeral  being  placed  at  the  point  of  the  most  intense 
pain  and  also  on  the  line  inclosing  the  pain  area  or  indicating  the 
pain  radiation.  Thus  it  may  be  seen  that  the  primary  characters 
can  only  be  used  in  every  fourth  marking,  but  that  the  number 
of  markings  may  be  multiplied  indefinitely.  Figure  43  illustrates 
this. 

"Figure  I,  in  Fig.  43,  shows  the  first  marking  upon  a  patient, 
who  we  assume  complained  of  a  painful  area,  a  center  pain  within 
the  area,  and  a  radiation  of  pain.  It  will  be  seen  that  the  area  of 
pain,  its  more  painful  center,  and  the  radiation  of  pain  from  the 
area  of  pain  are  constructed  from  the  first  primary  character. 

"Figure  II,  in  Fig.  43,  shows  the  second  marking  upon  the 
patient  who  complained  of  a  painful  area  with  a  more  painful 
point  within,  which  we  designated  as  a  center  pain.     The  boun- 


METHOD    or    RECORDING   PAIN 


137 


y^       ^\ 

^  -~  *- ^      \ 

/       ^ 

\ 

'^                   J 

(    o 

^  . 

>  >       > 

\ 

/ 

V                                  y 

/ 

\          ^/ 

V    ^ 

rig.    I 

^   _    ^                   Tig.    n 

.--•                                -. 

/                                                     \ 

_ 

•                                                                                                                 • 

*  • 

/                                           1                \ 

•  • 

\ 

fig.  in 

^•-— •—•—•— '-^        Fig.  IV 

^ s-      ^ 

^    ■ 6-^ 

\ 

\ 

/                                                    \ 

y 

/                                            N 

1            s 

y^""^ 

V y 

F.9.  V 

^ •    -^Rg.Vf 

.'-—.-.._.— -^"'N 

•    ••>^.    ••••    .■V. 

•  ••^*  ••••  •>• 

Fig.Vn 

V.^«^        Fig.  Vra 

^  —  10  ^                   __ 

/^ ^^   ^         N 

/^                       "v 

''/                                >                » 

'i          ii2               U^^ 

^                    ,// 

fig.  IX 

\  V,                      //        Fig.  X 

\  >-  -  ^  '^^ 

'  "*-    il   ^' 

Fig.  43. — Figures  Showing  the  Application  of  the  Marking  Code  of 

Dr.  Harris. 


dary  of  the  painful  area  is  formed  from  the  second  primary  char- 
acter, as  is  also  its  center  of  pain  shown  by  the  Greek  cross. 

"Figure  III,  in  Fig.  43,  shows  the  third  marking  upon  the 
patient  who  complained  of  simply  1  painful  point.     The  four  dots 


138  THE   INTENSITY    OF   PAIN 

arranged  in  eqiii-latcro-qiiadrangular  formation  show  the  manner 
of  marking  a  painful  point  or  a  center  of  pain  from  the  third 
primary  character. 

"Figure  IV,  in  Fig.  43,  shows  the  fourth  marking  upon  the 
patient,  ilhistrating  a  painful  area  and  a  center  of  pain.  The 
markings  are  constructed  by  using  the  dot  and  dash,  which  consti- 
tute the  fourth  primary  character. 

"Figiire  V,  in  Fig.  43,  demonstrates  a  painful  area  and  a 
center  pain. 

"Figure  VI,  in  Fig.  43,  shows  the  sixth  marking.  The  dashes 
are  employed,  as  in  the  case  of  the  second  marking,  but  here  the 
insertion  of  the  Arabic  numeral  6  indicates  the  number  of  the 
marking. 

"In  Figure  VII,  in  Fig.  43,  the  Arabic  numeral  at  the  begin- 
ning of  the  dotted  line  shows  the  painful  point,  and  the  dotted 
line  indicates  the  direction  of  radiation. 

"In  Figure  VIII,  in  Fig.  43,  the  boundary  of  the  pain  area  is 
constructed  from  the  fourth  primary  character,  the  insertion 
of  the  numeral  8  distinguishing  it  from  the  fourth  marking. 
The  location  of  the  figure  8  at  three  different  points  indicates 
the  location  of  the  pain  at  three  distinct  points. 

"The  Arabic  numeral  9  in  the  ninth  marking  of  the  patienfc 
indicates  a  j)ainful  point,  while  the  continuous  arrowed  line,  con- 
structed from  the  first  primary  character,  illustrates  a  radiation 
of  pain  from  the  marked  painful  point. 

"Figure  X,  in  Fig.  43,  shows  a  recurrence  of  pain  in  the 
same  region  as  shown  by  the  second  marking  of  the  patient.  In 
this  tenth  marking  of  the  patient  the  boundary  of  the  area  of 
pain  is  constructed  from  the  second  primary  character.  The 
number  10  in  the  outer  boundary  line  of  the  area  distinguishes 
this  boundary  line  from  the  boundary  line  of  the  second  marking, 
which  occurred  in  the  same  region  having  a  longer  and  narrower 
area.  The  number  10  in  this  tenth  marking  shows  the  location 
of  the  center  of  pain,  and  distinguishes  it  from  the  center  of 
pain  indicated  by  the  Greek  cross  of  the  second  marking  of  this 
patient." 


METHOD    OF    RECORDING    PAIN  139 

A  permanent  record  may  be  made  on  the  patient's  chart  by 
transferring  the  outlines  on  the  patient's  body  to  a  stamped  figure, 
being  careful  that  the  relative  positions  of  the  outlines  correspond 
both  with  the  bony  landmarks  on  the  figure  and  on  the  patient's 
body. 


CHAPTER  VIII 

PAIN   IN   DISEASES    OF    THE    NERVES,   BRAIN,    AND    CORD 

The  nervous  system,  since  it  is  the  carrier  of  impulses  from 
one  portion  of  the  body  to  another,  and  since  its  organization  is 
much  more  delicate  than  that  of  any  other  structure  of  the  body, 
suffers  from  disturbances,  which,  when  affecting  the  sensory  ele- 
ments, are,  as  a  rule,  announced  by  pain.  For  systematic  consid- 
eration the  following  divisions  may  be  made:  (1)  nerve  terminals; 
(2)  nerves  or  nerve  trunks;  (3)  nerve  plexuses;  (4)  nerve  roots; 
(5)  cord  lesions;  and  (6)  pontine,  mid-brain  and  cortical 
lesions. 

AFFECTIONS  OF  THE  NERVE  TERMINALS  AND  NERVE 

TRUNKS 

Affections  of  the  nerve  receptors  are  due,  as  a  rule,  either  to 
inflammation,  to  toxemia,  or  to  pressure.  These  have  been  con- 
sidered in  part  in  the  section  on  parenchymatous  pain  (q.  v.). 

Affections  of  the  nerves  or  nerve  trunks  are  due,  as  a  rule,  to 
the  following  causes:  (a)  congestion;  (b)  inflammation;  (c)  in- 
jury (traumatism,  j)ressure)  ;  and  (d)  toxemia.  The  milder 
grades  may,  for  purposes  of  convenience,  be  termed  neuralgias; 
the  more  severe  affections,  neuritis. 

The  distinctions  between  neuralgia  and  neuritis  are  quantita- 
tive rather  than  qualitative.  It  is  largely  a  matter  of  degree.  A 
severe  neuralgia  may  be  termed  a  neuritis ;  a  mild  neuritis  a  neu- 
ralgia. We  cannot,  therefore,  insist  upon  a  separation  of  the  two 
conditions.  One  finds  one  or  all  of  the  causes  operative  in  pro- 
ducing either  a  neuralgia  or  a  neuritis  and  the  resulting  lesion  de- 
140 


AFFECTIONS    OF    THE    NERVE    TERMINALS  141 

pends  largely  upon  the  severity  of  the  action  of  the  exciting  factor. 
Thus  exposure  to  cold  may  set  up  a  neuralgia  in  the  facial  from 
involvement  of  its  sensory  roots  (the  geniculate  ganglion),  or  it 
may  cause  a  true  neuritis,  involving  the  motor  components,  as  well. 
Similarly  an  inflammatory  reaction  in  a  mixed  nerve  may  cause 
only  slight  pain,  the  sensory  components  being  involved  but 
slightly,  or  it  will  bring  about  both  sensory  and  motor  disturbances 
with  distinct  neuritis  symptoms;  slight  traumata,  as  well  as  tx)x- 
emias,  cause  quite  similar  pictures. 

Certain  meningeal  diseases  of  the  cord,  as  well  as  ganglion 
affections,  give  rise  to  exquisite  neuralgic  symptoms  without  any 
of  the  usual  motor  complexities  of  a  neuritis. 

We  shall  here  discuss  the  so-called  neuralgia,  although  it 
should  be  remembered  by  the  reader  that  one  is  continually  stray- 
ing into  the  field  of  neuritis. 

Anstie,  in  his  classical  work  on  "iN^euralgia  and  the  Diseases 
Which  Resemble  It"  (1871),  gave  one  of  the  first  English  presen- 
tations of  the  general  subject.  Bernhardt,  in  ISTothnagel's  large 
system,  has  given  the  most  extensive  of  recent  discussions  of  the 
whole  subject.  However,  he  was  incorrect  in  regarding  neuralgia 
as  a  separate  entity.  It  should  not  be  so  regarded,  with  the  pos- 
sible exception  of  a  few  conditions,  for  instance,  those  which 
cause  such  a  change  in  the  conducting  apparatus  that  a  light 
stimulus  is  interpreted  as  painful,  or  pain  is  produced  without 
any  apparent  stimulus.  Such  a  condition  may  follow  slight  chill- 
ing of  the  surface,  or  the  lodginent  in  the  nerve  or  its  sheath  of 
toxic  substances,  either  heterotoxic  (phosphorus  or  mercury),  or 
autoxic,  the  result  of  deranged  metabolism.  Such  a  condition  is 
present  in  influenza,  and  also  in  old  age,  when,  because  of  im- 
paired circulation,  the  tissues  are  not  properly  nourished.  To 
these  pains  the  term  neuralgia  may  be  applied.  As  early  as  1873,^ 
Loomis  also  applied  the  term  to  conditions  in  which  there  is  a 
disturbance  of  nutrition.  Neuralgia  seems  to  be  without  recog- 
nizable pathology;  at  least,  no  uniformity  exists  as  to  the  kind  of 
pathology  which  is  present.    By'some  it  is  thought  to  be  a  form  of 

1  Loomis,  Med.  Becord,  N.  Y.,  1873,  p.  473. 


142     PAIN  IN  DISEASES  OF  THE  NERVES,  BRAIN,  AND  CORD 

neuritis  (neuritis  of  the  ncrvi  nervorum,  Thompson,  352),  but  it 
differs  considerably  from  neuritis  in  its  pain  phenomena. 

Etiology. — By  many  authors  neuralgia  is  the  name  given  to 
a  nerve-jiain  "which  is  produced  by  any  of  the  following  causes : 

Exciting  Causes. — Intraneural,  in  which  the  exciting  cause 
is  found  in  the  nerve  fiber  or  its  central  origin.  This  cause  may, 
in  many  cases,  be  the  presence  of  toxic  materials  producing  irri- 
tation and  pain  somewhat  akin  to  the  action  of  rheumatic  poisons 
in  rheumatic  myalgia,  in  which  the  poisons  act  upon  the  terminal 
filaments  of  the  sensory  nerves  distributed  to  the  muscles.  Under 
this  heading  we  would  include  all  those  pains  of  infectious  origin 
which  do  not  result  definitely  from  an  inflammatory  change  in 
the  nerves,  such  as  occur  in  acute  infectious  diseases  (influenza, 
tonsillitis,  common  colds),  malaria,  gout,  nephritis,  anemia 
(chlorosis),  diabetes,  syphilis,  typhoid  fever,  small  pox,  constipa- 
tion, and  gonorrhea.  Many  consider  copper,  lead,  arsenic,  alco- 
hol, nicotin,  and  mercury  causes  of  neuralgia ;  others  class  them 
rather  as  irritant  poisons  with  the  production  of  neuritis.  Other 
causes  are  molecular  changes  in  the  nerve  itself,  the  character  of 
which  we  do  not  know,  although  many  regard  them  as  a  mild  de- 
gree of  inflammation.  Also  included  under  the  heading  of  mole- 
cular disturbance  pain  are  pain  caused  by  exposure  to  cold  (we 
are  all  aware  of  the  headache  produced  by  going  against  the  wind 
on  a  cold  day)  and  post-hoc-neuralgia,  a  term  given  to  those  con- 
ditions in  which,  following  the  removal  of  the  cause  of  the  neu- 
ralgia, there  is  a  persistence  of  the  pain,  due,  perhaps,  to  continued 
molecular  change  in  the  nerve  substance  or  ganglion,  which  time 
alone  can,  but  does  not  always  remove.  As  an  instance  of  this 
may  be  mentioned  the  pain  persisting  after  removal  of  gall  stones, 
after  the  removal  of  carious  teeth,  and  after  cure  of  a  gastric  ulcer. 
Sometimes  these  are  called  "habit  pains"  (q.v.). 

Extramural,  under  which  we  would  include  pressure  by  new 
growths,  tumors,  or  bony  processes,  by  foreign  bodies,  soft  tissues, 
glands,  bone  (especially  when  the  nerves  pass  through  bony  fora- 
men), cicatrices,  misplaced  visc^a,  hernia,  aneurysms,  enlarged 
uterus,  etc.,  upon  the  nerve. 


AFFECTIONS    OF    THE   NERVE    TERMINALS  143 

Traumatism,  such  as  injury  of  tlie  nerve  by  a  blow,  by  forcible 
contact  with  a  foreign  body,  by  the  pinching  of  a  nerve  between 
two  bones,  as  pinching  of  the  intercostal  nerves  between  two  adja- 
cent ribs.  Fractures  by  pressure  from  fragments,  or  from  the 
callus,  cause  nerve  pain.  Dislocation  of  a  bone  may  also  cause 
pain. 

Infection  has  been  mentioned  as  one  of  the  causes,  and  perhaps 
it  is  the  chief  one.  Cases  of  epidemic  intercostal  and  of  supra- 
orbital neuralgia  have  been  described,  as  well  as  the  neuralgia 
associated  with  typhoid  fever  and  rheumatism.  It  is  reasonable 
to  suppose  that  the  infective  germs  can  lodge  and  grow  in  nerves 
as  well  as  in  blood  and  interstitial  tissues,  for  it  has  been  defi- 
nitely proven  by  many  observers  that  typhoid  fever  germs  are, 
in  the  later  stages  of  the  disease,  freely  circulating  in  the  blood. 
Pneumococci,  streptococci,  and  various  other  germs  have  also  been 
isolated  in  pure  culture  from  the  blood;  and  these  wandering 
hither  and  thither  in  the  tissues  locate  themselves  where  there  is 
the  least  resistance,  be  this  in  bone,  tendon,  nerve,  or  muscle. 
Should  the  nerve  be  the  habitat,  a  mild  neuritis  is  produced 
and  this  causes  pain. 

Predisposing  factoes  leading  to  the  production  of  neuralgia 
are  inherited  predisposition,  the  use  of  alcohol,  tobacco  and 
drugs,  neurasthenia,  and  excessive  sexual  indulgence.  Age  seems 
also  to  act  as  a  predisposing  factor,  those  of  advanced  age  being 
more  susceptible  than  those  who  are  younger.  The  other  so-called 
pains  are  classified  under  referred,  projected,  sympathetic  pain, 
et  cetera,  under  which  they  will  be  described  (q.  v.). 

Symptoms.- — In  the  case  of  pain  occupying  any  restricted 
area  it  is  well  to  make  an  examination  for  local  inflammatory 
changes  in  the  skin  and  subjacent  tissues.  Should  they  be  absent, 
with  the  skin  very  sensitive  to  light  pressure  and  the  deeper  tissues 
not  so  sensitive,  we  may  conclude  that  the  cause  of  the  pain  is 
either  a  neuralgia  or  a  neuritis. 

If  neuralgia  is  present  there  are  points  of  hyperesthesia  and 
the  course  of  the  nerve  is  not  painful  to  pressure,  while  in  neuritis 
the  course  of  the  nerve  is  tender  to  pressure,  and  there  are  no 


144     PAIN  IN  DISEASES  OF  THE  NERVES,  BRAIN,  AND  CORD 

painful  points.  Should  neuralgia  be  suspected,  we  must  seek 
the  cause,  and  consider  acute  infections,  reflex  irritations,  as  the 
cephalgias  due  to  visceral  disorders ;  referred  pain,  as  earache  due 
to  decayed  teeth ;  projected  pain,  as  in  the  head  after  Gasserian 
ganglion  resection,  and  sympathetic  pain,  when  one  sensory  center 
is  affected  by  changes  in  another  center,  and  pain  is  felt  as  coming 
from  the  area  of  distribution  of  nerves  arising  in  this  center. 

The  pain  of  neuralgia  may  be  constant  and  dull,  or  there  may 
be  periods  of  freedom  from  pain  and  then  times  of  sudden  and 
severe  pain.  These  paroxysms  of  pain  occur  at  intervals  varying 
from  a  few  seconds  to  as  many  weeks.  The  duration  of  an  indi- 
vidual paroxysm  varies  from  a  few  seconds  to  as  many  minutes. 
Sometimes,  after  the  pain  reaches  its  acme  it  becomes  almost  con- 
tinuous and  may  last  for  weeks.  The  onset  in  many  cases  seems 
to  be  without  any  causal  condition,  and  may  be  sudden  or  grad- 
ual. Abortive  attacks  may  come  quickly  and  quickly  disappear. 
Sensations  of  cold,  itching,  and  numbness  in  the  areas  of  the  skin, 
which  subsequently  are  affected  by  the  neuralgia,  are  premoni- 
tory signs  of  an  attack.  The  pains  are  of  a  burning,  darting,  bor- 
ing, cutting,  piercing,  biting,  or  pulling  character.  In  some  cases 
there  is  an  intermittency  in  the  paroxysms,  which  may  come  every 
day  or  every  second  or  third  day.  When  this  occurs  examine  for 
malaria.  The  pain  generally  follows  the  course  of  a  peripheral 
nerve.  It  may  remain  confined  to  one  nerve  area  throughout  its 
course,  or  it  may  suddenly  shift  from  one  area  to  another.  At 
times  it  is  confined  to  a  small  area,  but  most  often  it  radiates 
through  large  areas  and  may  run  toward  the  periphery  (neural- 
gia descendens),  or  from  the  periphery  inward  toward  the  cen- 
ters  (neuralgia  ascendens). 

Anesthesia  dolorosa  (q.  v.)  sometimes  is  present  in  these  con- 
ditions, especially  when  the  nerve  trunk  is  subject  to  pressure  due 
to  an  irritative  lesion.  In  neuralgia  tactile  sensation  also  is  some- 
times lost. 

Local  Points. — Pressure  points,  first  described  in  1841  by 
Valleix,  are  called  Yalleix's  points.  Light  pressure  on  these  points 
sometimes  aggravates  the  pain,  while  heavy  pressure  relieves  it. 


AFFECTIONS    OF    THE    NERVE    TERMINALS  145 

In  other  cases  the  reverse  is  noticed.  Pain  may  he  elicited  by  pres- 
sure with  a  single  finger-tip. 

The  galvanic  current  sometimes  produces  pain  when  finger 
pressure  fails  to  produce  it.  (Technique:  Place  the  positive  pole 
on  any  part  of  the  body,  preferably  over  some  part  of  a  nerve; 
hold  it  stationary,  and  run  the  negative  pole  along  the  course 
of  the  nerve.)  In  neuralgia  Valleix's  points  are  found  at  the 
point  of  emergence  of  the  nerve  trunks,  at  sections  where  a  nerve 
trunk  traverses  a  muscle  to  reach  the  skin,  at  the  point  where 
a  nerve  fiber  breaks  up  into  branches,  and  at  points  where  the 
nerve  becomes  very  superficial.  The  painful  points  along  the 
course  of  nerves  in  neuralgic  affections  may  be  due  to  irritation 
of  fine  terminal-sensory  filaments,  which  are  distributed  to  the 
sheath  of  the  nerves  (Jelliffe). 

Distant  Poiiits. — "Points  douloureux  apophysaires"  of  Trous- 
seau, or  distant  painful  points,  are  also  found  in  neuralgia. 
These  are  located  in  the  spinous  processes  of  the  vertebra,  be- 
tween which  the  roots  of  the  affected  nerves  leave  the  verte- 
bral canal.  The  spinous  processes  in  the  region  of  the  middle 
cervical  vertebra  are  very  sensitive  in  neuralgia  of  the  trigeminal 
nerve. 

While  painful  points  vary  greatly  and  sometimes  are  recog- 
nized only  at  the  time  of  the  paroxysm,  they  may  exist  all  the 
time  and  become  more  painful  only  at  the  time  of  the  paroxysm. 
Pressure  on  the  painful  points  may  in  one  case  produce  an  attack, 
while  in  another  case  it  may  abort  the  attack.  The  effect  is  some- 
times lessened,  sometimes  intensified,  depending  upon  whether  the 
pressure  is  light  or  heavy.  Light  pressure  sometimes  produces  a 
paroxysm,  while  heavy  pressure  sometimes  causes  its  disappear- 
ance. After  the  neuralgia  has  existed  a  certain  length  of  time, 
atrophy  of  the  nerve  may  occur  and  the  pain  may  subside,  espe- 
cially when  it  is  due  to  pressure  along  the  course  of  the  nerve. 

Vasomotor  Changes. — In  acute  and  recent  attacks,  because  of 
the  contraction  of  the  vessels  and  stimulation  of  the  vasomotor, 
there  may  be  at  first  pallor  of  the  affected  area,  followed  by  flush- 
ing.    In  chronic  neuralgia  there  is  chronic  flushing,  due  to  vaso- 


146     PAIN  IN  DISEASES  OF  THE  NERVES,  BRAIN,  AND  CORD 

motor  paresis.  In  later  attacks  there  is  generally  flushing  of  the 
skin  on  the  affected  area.  In  trigeminal  neuralgia  there  may  be  a 
pulsation  of  the  temporal  artery  on  the  affected  side.  In  some 
cases  a  swelling  of  the  affected  side  occurs,  and  this  in  time  leads 
to  chronic  thickening. 

Trophic  Changes. — The  skin  is  sometimes  thicker  than  nor- 
mal; or,  as  a  rarer  condition,  it  may  be  thinner,  due  to  cutaneous 
atrophy.  The  hair  on  the  affected  side  of  the  head  in  trigeminal 
neuralgia  sometimes  becomes  coarse  or  rough,  and  falls  out,  or  it 
may  become  gray.  Areas  of  gray  hair  may  alternate  with  the  na- 
tural-colored hair.  In  some  cases  the  hair  grows  profusely.  Other 
changes,  as  herpes,  desquamation,  eczema,  and  pemphigus,  are 
fairly  common.  The  secretory  and  excretory  apparatus  are  also 
affected.  Saliva  and  tears  are  often  increased  on  the  affected  side 
in  trigeminal  neuralgia.  Sweating  is  common  over  the  affected 
part,  and  urine  is  often  excreted  in  abnormal  amounts.  The  nasal 
secretion  in  a  trifacial  neuralgia  is  at  times  tinged  with  blood. 

Muscular  Changes. — Atrophy  of  the  muscles  on  the  affected 
side  is  common.  It  is  due  to  lack  of  motion,  because  of  pain. 
The  atrophy  is  very  slow  of  onset,  and  after  a  certain  time  remains 
stationary.  Trophic  muscular  changes  generally  indicate  a  more 
extensive  involvement  (protopathic  system). 

Muscular  contractions  occur ;  at  times  they  are  clonic,  at  other 
times  tonic.  Slowing  of  the  heart's  action  has  been  observed  dur- 
ing a  neuralgic  attack.  Movement  is  often  impossible,  because  of 
the  irritation  produced  in  the  sensory  nerves.  Walking  and  flex- 
ing of  the  thigh  will  often  produce  pain  in  cases  of  sciatica.  Eat- 
ing will  frequently  produce  pain  in  cases  of  trigeminal  neuralgia. 
Pupils  are  often  dilated,  the  dilatation  being  unequal.  Associated 
neuralgia  may  be  present  in  some  cases.  Here  the  pain  gradually 
appears  on  the  opposite  side  of  the  face,  and  may  then  entirely 
disappear  in  the  region  where  it  commenced. 

Duration  of  Neuralgia. — Sometimes  the  disease  ends  after 
one  or  two  attacks,  or  it  may  persist  for  long  years,  even  for  an 
entire  lifetime. 

Diagnosis  of  Neuralgia. — Xeuralgia    can    only    be    diagnosed 


AFFECTIONS    OF    THE    NERVE    TERMINALS  147 

by  exclusion,  and  is  only  justifiable  when  all  other  causes  having 
an  anatomical  basis  for  the  pain  production  have  been  excluded, 
such  as  pressure  from  growths,  inflammatory  exudates,  misplaced 
fragments  of  bone,  etc.  The  term  neuralgia  is  often  only  a  cloak 
for  ignorance.  It  indicates  that  the  diagnostician  has  not  been 
able  to  localize  the  cause  of  the  painfuj  condition.  It  is  the  same 
as  calling  a  pain  in  the  head  headache,  or  a  lesion  of  the  heart 
heart  disease. 

DiFrERE::^TiAi,  diagnosis  of  neuralgia  should  be  made  from 
painful  muscular  lesions.  .  Here  the  muscle  is  tender  to  pressure, 
and  there  are  swelling  and  thickening.  Pain  never  extends  be- 
yond the  region  of  the  muscle.  Inflammation  of  the  bones  or 
periosteum  is  also  to  be  distinguished.  In  these  there  are  swell- 
ing and  tenderness  in  the  bones  affected.  Inflammation  of  the 
joints  sometimes  is  mistaken  for  neuralgia;  it  is  differentiated 
by  the  swelling  and  tenderness  of  the  joints  and  the  pain  on  mov- 
ing them.  Xeuritis  from  a  differential  diagnostic  standpoint 
offers  the  greatest  difficulties.  It  is  different  from  neuralgia,  in 
that  neuralgia  is  but  the  name  of  the  sensory  condition,  while 
neuritis  is  the  name  of  the  pathological  entity  which  is  present. 

Syphilitic  Neuralgia. — This  form  of  neuralgia,  because  of  the 
frequency  with  which  it  is  entirely  overlooked,  merits  separate 
consideration.  Neuralgia  may  occur  during  any  of  the  three 
stages  of  syphilis.  During  the  first  stage  it  is  manifested  princi- 
pally by  fugitive  transitory  pain  over  the  entire  body.  It  is 
rather  an  aching  than  a  well-defined  pain.  In  the  second  stage, 
the  pain  also  is  fugitive,  is  worse  at  night,  and  shows  remarkable 
improvement  under  syphilitic  treatment ;  while  in  the  third  stage 
the  pains  are  more  fixed  and  are  due  to  pressure  from  syphilitic 
changes  in  the  surrounding  tissues  (gumma,  exostosis),  or  they  are 
produced  by  changes  in  the  nerve  itself,  due  to  syphilitic  processes 
such  as  are  found  in  locomotor  ataxia. 

Types  of  Neuralgia  According  to  Localization. — The  principal 
types  of  neuralgia,  according  to  localization,  are:  (1)  trigeminal; 
(2)  brachial;  (3)  intercostal;  (4)  circumflex;  (5)  sciatic;  (6) 
peroneal;  and  (7)  visceral. 


148     PAIN  IN  DISEASES  OF  THE  NERVES,  BRAIN,  AND  CORD 

Trigeminal,  Neuralgia  (Tic  Douloureux). — Neuralgia  may 
occur  in  any  of  the  branches  of  the  fifth  nerve.  In  some  cases 
lesions  have  not  been  demonstrable,  but  in  the  majority  of  in- 
stances some  disease  of  the  Gasserian  ganglion  has  been  found  in 
intractable  cases  of  tic  douloureux. 


1st  Br.  5th  nerve. 
Srd  Br.  5th  nerve. 


f —  —  — 2nd  Br.  5th  nerve. 

Points  of  tenderness 
in    involvement    of 

'  "  3rd  division  of  5th 

nerve. 

-  —  —  —  —  —  —--•  Points  of  tenderness 

in  involvement  of 
the  upper  cervical 
nerves. 


Fig.  44. — Areas  of  Neuralgic  Pain. 
The  first  branch  involvement  is  seen  most  often  by  physicians;  the  second 
and  third  division  involvement  are  seen  most  frequently  by  dentists. 
The  dots  indicate  Vallei.x's  points  of  tenderness  in  neuralgia  of  the 
fifth  nerve.  The  crosses  indicate  the  points  of  tenderness  in  cervico- 
occipital  neuralgia. 

The  most  important  of  the  peripheral  trigeminal  pains  due  to 
lesions  of  the  nerve  are  in  the  teeth.  In  some  cases  the  pain  is 
referred  to  areas  supplied  by  a  different  branch  of  the  nerve  than 
that  which  supplies  the  particular  tooth.  In  other  cases  a  central 
pain  is  referred  to  the  teeth.  One  of  the  most  frequent  mistakes  of 
dentists  is  to  consider  a  tic  douloureux  as  being  due  to  teeth  dis- 
orders. The  result  is  the  extraction  of  all  the  teeth  for  a  lesion 
which  really  is  in  the  Gasserian  ganglion. 

The  nose  in  many  cases  acts  as  a  cause  for  neuralgia  of  the  upper 


AFFECTIONS   OF  THE   NERVE  TERMINALS  149 

branch.  Thompson  mentions  a  case  of  trigeminal  neuralgia  which 
was  caused  by  a  piece  of  necrosed  bone  in  the  nose. 

Lange  calls  attention  to  neuralgia  being  mistaken  for  incipient 
tabes.  Diagnostic  differentiation  in  tabes  is  the  lack  of  sensitive- 
ness of  the  nerve  trunks,  and  generally  the  simultaneous  affection 
of  the  trigeminal  and  occipital  nerves.  On  the  other  hand,  a  tabes 
may  have  its  initial  symptom  in  a  trigeminal  neuralgia.  Neoplasms, 
gliomata,  etc.,  at  the  base  of  the  tongue  have  caused  neuralgia 
which  speedily  disappeared  after  their  removal  (Coates). 

Blair  gives  the  following  as  characteristics  of  trigeminal  neu- 
ralgia: (a)  The  pain  is  generally  sudden  in  one  branch  of  the 
fifth  nerve;  (b)  it  is  paroxysmal  and  always  returns  in  the  same 
spot;  (c)  it  is  spontaneous,  or  is  produced  by  certain  definite  stim- 
uli peculiar  to  the  individual;  (d)  no  primary  anesthesia  is  pres- 
ent over  the  involved  nerve;  (e)  there  is  no  tenderness  of  the 
trunks  of  the  involved  nerve. 

When  trigeminal  neuralgia^  is  present  in  any  or  all  branches 
of  the  fifth  nerve,  examine  the  branch  involved  from  its  area  of 
distribution  to  its  point  of  emergence  on  the  face.  True  trigemi- 
nal neuralgia  is  due  to  a  lesion  of  the  Gasserian  ganglion,  and 
should  not  be  confused  with  the  nerve  pain  arising  from  inflam- 
mation of  the  nerves,  tumors  of  the  nerves,  injury  of  the  nerves, 
pressure  upon  the  nerves  from  new  growths  (as  aneurysm  of  the 
carotid  artery),  tuberculosis  of  the  bony  foramen  through  which 
the  different  branches  pass,  gummata,  and  malignant  growths.  In 
infectious  diseases,  as  influenza,  malaria,  and  typhoid  fever, 
the  severest  pain  is  felt  at  the  supraorbital  foramen  (Schmidt). 

The  pain  of  trigeminal  neuralgia  is  probably  the  most  severe 
of  any  to  which  man  is  heir.  As  a  rule  it  is  unilateral.  When 
at  its  worst  the  sufferer  may  cry  out,  roll,  and  toss  in  his  agony. 
With  a  constant,  steady  pain,  there  occur  paroxysms  of  greater 
severity,  which  are  so  intense  that  the  patient  would  welcome  any 
event,  even  death  itself,  if  it  would  relieve  him.  If  the  inferior 
or  middle  branches  are  involved,  eating  becomes  an  utter  impossi- 
bility, and  drinking  is  only  accomplished  with  great  distress.  The 
patient  is  in  constant  dread,  for  when  the  pain  is  somewhat  les- 


150     PAIN  IN  DISEASES  OF  THE  NERVES,  BRAIN,  AND  CORD 

sened  the  slightest  touch,  even  tlie  vibration  from  a  slammed  door, 
Avill  again  cause  a  paroxysm.  These  attacks  last  from  a  few 
minutes  or  hours  to  several  days. 

Valleix's  points,  which  are  present,  are  described  by  Jelliffe: 
(a)  for  the  first  division  of  the  fifth  nerve,  as  being  located  at 
the  supraorbital  notch,  the  external  angle  of  the  upper  lid,  the 
upper,  outer  aspect  of  the  nose,  and  the  globe  of  the  eye ;  and  (b) 
for  the  second  division  at  the  infraorbital  notch,  the  molar  bone, 
opposite  the  upper  last  molar,  at  the  outer  angle  of  the  mouth, 
and  on  the  roof  of  the  mouth.  The  points  of  tenderness  (c)  in  the 
inferior  maxillary  involvement  are  just  in  front  of  the  auditory 
canal,  the  side  of  the  tongue,  the  border  of  the  chin,  and  Trous- 
seau's points  over  the  first  and  second  cervical  vertebral  spines. 

Bkachial  I^euralgia. — Brachial  neuralgia,  or  neuritis,  is 
due  to  a  lesion  of  the  brachial  jdIcxus.  The  brachial  plexus  arises 
from  the  anterior  roots  of  the  lower  four  cervical  nerves  and  the 
upper  half  of  the  first  dorsal  nerve.  These  then  imite  into  trunks, 
the  fifth  and  sixth  uniting  to  form  the  upper  trunk,  the  seventh 
nerve  forming  the  middle  trunk,  and  the  eighth  cervical  and  one- 
half  of  first  dorsal  nerves  uniting  to  form  the  lower  trunk  (Fig. 
45).  These  trunks  then  divide  into  an  anterior  and  a  posterior 
part,  the  anterior  portion  of  the  upper  t"wo  trunks  again  uniting  to 
form  the  upper  cord,  and  the  posterior  divisions  of  the  upper  and 
middle  trunk  uniting  to  form  the  middle  or  posterior  cord.  The 
inferior  trunk  continues  as  the  inferior  or  lower  cord.  Each  of 
these  cords  is  made  up  of' both  motor  and  sensory  nerves. 

The  sensory  cutaneous  nerves  arising  from  the  upper  cord  of 
the  plexus  are  the  musculocutaneous,  from  the  fifth,  sixth  and 
seventh  cervical  roots.  Those  arising  from  the  lower  or  inner 
cord  are  the  lesser  internal  cutaneous,  which  arises  from  the  first 
dorsal;  the  internal  cutaneous,  arising  from  the  eighth  cervical 
and  the  first  dorsal ;  the  ulnar,  receiving  its  fibers  from  the  eighth 
cervical  and  first  dorsal  roots;  and  the  meridian  (inner  head), 
arising  from  the  sixth,  seventh,  and  eighth  cervical  and  the  first 
dorsal  nerves.  From  the  middle  cord  arises  the  circumflex,  re- 
ceiring  fibers  from  the  seventh  and  eighth  cervical ;  and  the  mus- 


AFFECTIONS  OF  THE  NERVE  TERMINALS 


151 


ciilospiral,  radial  branches  receiving  fibers  from  the  seventh,  eighth 
cervical  and  first  dorsal  roots.  A  lesion  in  any  one  of  the  cords 
of  the  brachial  plexus  may  produce  pam  in  the  area  of  distribution 


NFRA'iPINkTUS 


SHOULDER  JOINT 
SKIN  OVER  OELlOlO 
OEUOIO 

.SKIN  OVER  LOWER  % 
POSTERIOR  SURFACE 
DELTOID  AND  THE 
LONG  HEAD  Of  TRICEPS 


-INTEGUMEMT  Ot 

RADIAL  BORDER 

OF  FOREARM 


.  DORSAL  ft  PALMAR 
INTEROSSEOUS 
^ADDUCTORIS  TRANSVtRSUi   tt  0BLIQUI5   POLLIClS 
INNER  HEAD   FJ.EHOR  BREVlS  POLUCIS 


Fig.  45. — Brachial  Plexus. 
of  any  of  the  nerves  arising  from  it.     A  lesion  on  any  of  the 
nerves  derived  from  the  brachial  plexus  will  cause  pain  in  the 
area  of  distribution  of  the  nerves  involved.     The  areas  of  distribu- 


152     PAIN  IN  DISEASES  OF  THE  NERVES,  BRAIN,  AND  CORD 


Musculocutaneous. 


Supraclavicular. 


Palmar        Palmar 
cutaneous    branch 
branch        of 
of  ulnar,     ulnar. 


Fig.  46. — Areas  of  Distribution  of  Nerves  Derived  from  the  Brachiai. 

Plexus. 

tion  are  shown  in  the  accompanying  figures  (Figs,  46,  47). 
Should  the  lesion  occur  above  the  cords,  and  be  in  one  of  the  trunks, 
it  is  very  easy  to  define  it  by  referring  to  the  figures  showing  the 

Musculospiral.  Radial. 


Circumflex.     Internal  cutaneous.  Ulnar. 

Fig.  47. — Areas  of  Distribution  of  Nerves  Derived  from  the  Brachial 

Plexus. 


AFFECTIONS    OF    THE    NERVE    TERMINALS 


153 


distribution  areas  of  the  nerves  forming  the  brachial  plexus.  It 
is  only  necessary  to  remember  that  the  upper  trunk  is  formed  by 
the  fifth  and  sixth  cervical,  the  middle  trunk  by  the  seventh  cer- 
vical, and  the  lower  trunk  by  the  eighth  cervical  and  the  first  dor- 
sal nerves.  These  figures  (Figs.  46,  47)  clearly  show  the  areas 
of  pain  in  lesions  of  the  different  cervical  nerves.  The  accompany- 
ing outlines   (compiled  from  Piersol  and  Gray)   show  the  nerve 


Posterior  thoracic 

Suprascapular 

External  anterior  tho- 
racic   

Internal  anterior  tho- 
racic  

Subscapular 

Circumflex 

Musculocutaneous  . . .  . 

Median 

Lesser    internal     cuta- 


neous  

Internal  cutaneous. 

Ulnar 

Circumflex 

Musculospiral  .  .  .  . 


5  cervical 
5  cervical 

5  cervical 


5  cervical 
5  cervical 
5  cervical 


5  cervical 


6  cervical 
6  cervical 

6  cervical 


6  cervical 

6  cervical 

6  cervical 

6  cervical 


6  cervical 
6  cervical 


7  cervical 


7  cervical 


7  cervical 

7  cervical 

7  cervical 

7  cervical 


7  cervical 


8  cervical 


8  cervical 

8  cervical 

8  cervical 

8  cervical 

8  cervical 


8  cervical 

8  cervical 

8  cervical 

8  cervical 


1st  D. 


1st  D. 

1st  D. 

1st  D. 
1st  D. 
1st  D. 
1st  D. 
1st  D. 


roots  from  which  the  divisions  of  the  brachial  plexus  are  derived, 
and  are  very  useful  in  localizing  neuritis,  which  affects  both  the 
motor  and  the  sensory  fibers  of  the  nerves  involved.^ 

These  primary  distribution  areas  are  represented  in  the  out- 
lines in  such  a  manner  that  they  clearly  define  the  area  of  distri- 
bution of  the  different  nerves  forming  the  brachial  plexus.     Dia- 

1  The  table  may  be  used  to  define  the  cervical  nerve,  root  or  cord  zone  in- 
volved; for  instance,  suppose  pain  was  felt  on  the  ulnar  side  of  the  arm  and 
over  the  shoulder,  on  referring  to  the  figure  one  sees  that  the  pain  is  in  the 
area  of  distribution  of  the  ulnar  and  circumflex  nerves,  and  on  referring  to 
the  table  one  sees  that  while  the  circumflex  arises  from  the  seventh  and  eighth 
cervical  and  the  first  dorsal,  the  ulnar  arises  only  from  the  eighth  cervical  and 
first  dorsal.  The  lesion  may  involve  the  seventh  and  eighth  cervical,  and  the 
first  dorsal,  but  if  it  involves  the  first  dorsal,  the  lesser  internal  cutaneous  would 
also  be  involved.  Since  it  is  not,  the  first  dorsal  must  be  excluded.  Examina- 
tion of  the  internal  anterior  thoracic  will  show  whether  the  eighth  cervical  or 
the  seventh  cervical  are  the  ones  aftected.  If  it  is  involved  in  the  pain  phe- 
nomena also  the  eighth  cervical  is  the  nerve  affected. 


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154 


AFFECTIONS  OF  THE  NERVE  TERMINALS 


155 


grammatic  outlines  of  the  distribution  area  of  the  cords  compos- 
ing the  brachial  plexus  are  shown  in  Figiires  48-53.  A  lesion  on 
one  of  these  nerves  would  produce  a  disturbance  in  the  entire 
distribution  area  of  the  nerve  below  the  point  involved. 


Fig.  49. — Areas  of  Distribution  of  the  Different  Cords  of  the 
Brachial  Plexus. 
The  areas  marked  U  are  suppUed  by  the  upper  cord.     Those  marked  M  by 
the  middle  or  posterior  cord,  while  those  marked  L  derive  their  supply 
from  the  lower  or  inner  cord.    The  area  containing  crossed  hnes  and 
marked  U  M  is  supplied  by  both  the  upper  and  lower  cords. 

When  the  pain  is  bilateral,  and  atfects  the  areas  of  one  or 
more  segments  (see  figure  showing  cord  zone  distributed)  of  the 
cord,  disease  of  the  vertebra  or  tuberculosis  should  be  looked  for ; 
or,  if  it  affects  the  cord  itself,  tabes  should  be  sought.  The  asso- 
ciation of  herpes  indicates  involvement  of  the  posterior  ganglia. 

Unilateral  pain  occurring  (a)  within  the  boundaries  of  a  par- 
ticular cord-distribution  area,  (b)  within  the  distribution  area  of 
a  cord  trunk,  or  (c)  of  one  of  the  cervical  nerves,  or  (d)  even  of 
the   nerves  given  off  from    the  brachial   plexus,   should   always 


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157 


158     PAIN  IN  DISEASES  OF  THE  NERVES,  BRAIN,  AND  CORD 


cause  a  search  to  be  made  for  the  lesion  in  the  special  nerve  seg- 
ment in  which  it  has  been  localized.  Lesions  causing  such  a  condi- 
tion are  those  producing  pressure,  as  axillary  tumors,  sarcoma, 
aneurysm  of  the  subclavian  or  axillary  artery,  abscess,  and  en- 
largement of  the  cervical  and  axillary  lymph  glands.  Owing  to 
the  close  relationship  of  the  trunks  and  cords  forming  the  brachial 

plexus,  it  is  very 
unusual  for  one  to 
be  affected  to  the 
exclusion  of  the 
others. 

A  method  of 
making  pressure 
on  the  brachial 
plexus  and  so 
causing  pain  to  ap- 
pear in  the  distri- 
bution areas  in- 
volved is  shown  in 
the  figure. 

All  of  the  in- 
stances given  here 
are  not,  in  the 
strict  sense  of  the 
word,  true  cases  of 
neuralgia.  The 
term  neuralgia  should  be  used  only  to  define  those  lesions  of  the 
nerves  giving  rise  to  pain  and  in  which  there  is  no  ajiparent  pathol- 
ogy. Such  a  condition  is  found  in  anemia  and  toxemia.  In  other 
cases  pain  produced  by  pressure  is  referred  to  the  area  of  distribu- 
tion of  the  nerve,  and  is  a  referred  pain,  while  pain  resulting  from 
an  adjacent  inflammation  is  due  to  a  neuritis  or  to  jDressure  from 
the  inflammatory  exudate.  Both  cases  resemble  referred  j)ain ;  but 
since  it  is  common  to  consider  these  pains  under  neuralgia,  and 
neuralgia  itself  means  pain,  they  have  been  placed  under  this 
heading.     In  cases  in  which  inflammation  is  the  cause  of  the 


Fig.  54. — Method  of  Eliciting  Pain  in  Brach- 
ial Neuralgia. 


AFFECTIONS    OF    THE    NERVE    TERMINALS  159 

neuralgia  a  considerable  part  of  the  local  pain  is  as  much  the 
result  of  the  inflammatory  invasion  of  the  connective  and  muscu- 
lar tissues  of  the  affected  part  as  it  is  of  nerve  involvement; 
indeed,  it  is  probable  that  every  one  of  the  above  so-called  neu- 
ralgias will  be  found  to  be  a  neuritis. 

The  pain  in  brachialgia  is  similar  to  all  other  neuralgic  affec- 
tions. It  generally  occurs  in  sharp  paroxysms,  in  the  intervals 
between  which  there  is  no  pain;  yet,  in  some  cases,  the  pain  may 
be  constant,  and  of  a  dull,  aching  type.  In  all  cases  sharp 
paroxysms  of  greater  severity  occur  at  regular  intervals.  In  the 
early  stages  of  the  disorder,  the  pain  is  a  dull,  generalized  ach- 
ing, and  involves  the  entire  arm ;  then,  as  the  attack  persists,  it  be- 
comes localized  to  the  distribution  area  of  one  or  more  of  the 
cords  of  the  brachial  plexus  (page  155).  The  pain  may  be  so 
severe  that  the  patient  cannot  sleep,  and  even  though  he  should 
momentarily  doze  he  is  awakened  by  sharp  paroxysms  of  pain. 
All  sudden  and  forcible  motions  make  the  pain  worse,  but 
gentle  manipulation  is  painless.  In  brachial  neuralgia,  stretch- 
ing of  the  arm  causes  pain  in  the  region  over  the  posterior 
margin  of  the  scapula.  The  paroxysms  frequently  come  on 
at  night  and  it  is  nothing  unusual  for  the  patient  to  awake 
in  the  morning  suffering  from  arm  pains  of  the  greatest 
intensity. 

The  attacks  may  last  for  a  short  time,  a  few  minutes,  or  a 
few  hours ;  then  again,  they  may  be  present  for  weeks  or  months, 
during  which  time  the  pain  may  be  interrupted  by  periods  of  rest 
or  aggravated  by  paroxysms  of  great  severity.  An  individual 
attack  lasts,  on  an  average,  almost  two  or  three  weeks.  The  pa- 
tient seeks  rest,  and  it  is  comnion  to  find  him  sitting  in  an  arm- 
chair, nursing  the  diseased  arm  with  the  sound  one.  In  some 
cases  the  patient  lies  down  and  places  the  arm  across  his  chest 
or  abdomen. 

Location  of  the  Pain. — In  brachial  neuralgia  the  pain  may  in- 
volve the  entire  arm,  but  generally  only  the  upper  part  of  the 
arm  and  the  shoulder  are  most  severely  affected.  The  reason  for 
this  is  that  the  circumflex  and  the  internal  cutaneous  nerves  sup- 


160     PAIN  IN  DISEASES  OF  THE  NERVES,  BRAIN,  AND  CORD 

ply  the  shoulders  and  the  upper  part  of  the  arm,  and  are  the  most 
subject  to  injury. 

Should  the  pain  be  entirely  above  the  shoulder,  it  is  due  to 
involvement  of  the  acromial  and  clavicular  branches  of  the  fourth 
cervical.  If  the  pain  is  over  the  shoulder,  or  is  at  its  anterior  and 
outer  aspect,  it  indicates  involvement  of  the  circumflex  (Figure  on 
page  154).  Since  the  shoulder  joint  is  also  supplied  by  the  cir- 
cumflex nerve,  movement  of  the  joint  may  cause  pain  in  the  dis- 
tribution area  of  this  nerve.  If  the  circumflex  is  involved  the  pain 
is  confined  to  the  cutaneous  area  of  the  distribution  of  this  nerve ; 
but  should  the  pain  be  the  result  of  a  lesion  of  that  part  of  the 
cord  from  which  the  circumflex  arises,  the  pain  is  felt  also  down 
the  arm  in  the  area  of  distribution  of  the  musculospiral  nerve 
which  arises  from  the  posterior  cord  in  common  with  the  circum- 
flex. Should  the  pain  in  the  area  of  distribution  of  the  circum- 
flex be  associated  with  pain  over  the  scapula,  under  the  clavicle  or 
in  the  neck,  it  indicates  that  it  is  the  fifth  root  which  is  involved. 
In  disease  of  this  root  pain  may  also  extend  down  the  arm  in  the 
distribution  area  of  the  musculocutaneous  nerve. 

Pain  on  the  ulnar  side  of  the  arm,  extending  almost  half-way 
around  and  involving  the  hands  and  fingers,  except  the  dorsal 
and  external  surface  of  the  thumb,  the  index  finger,  and  the  adja- 
cent surfaces  of  the  index  and  the  ring  fingers,  indicates  involve- 
ment of  the  middle  cord  of  the  brachial  plexus.  Pain  in  the  radial 
side  of  the  forearm  generally  indicates  involvement  of  the  upper 
cord  of  the  brachial  plexus.  Depending  on  the  location  of  the 
lesion,  the  muscles  may  or  may  not  be  involved.  A  square  block 
has  been  placed  on  the  upper  trunk  of  the  brachial  plexus,  just 
before  it  divides  into  the  musculocutaneous,  and  the  branch  help- 
ing to  form  the  median.  A  lesion  at  this  point  would  not  disturb 
the  muscular  and  cutaneous  supply  of  the  nerves  given  off  above 
this  level,  while  the  supply  given  below  this  portion  would  be 
disturbed  in  the  manner  described  above.  By  placing  a  block 
on  any  part  of  the  nerve,  the  resulting  disturbance  can  easily  be 
ascertained. 

In  the  early  stages  of  brachialgia    the  pain  is  diffused  over 


AFFECTIONS    OF    THE    NERVE    TERMINALS  161 

the  entire  arm,  forearm  and  hand,  and  runs  down  into  the  fingers, 
though  it  usually  involves  only  the  first,  second  and  third  fingers 
(Dana).  According  to  Dana,  neuralgic  pain  in  the  forearm  is 
very  rare. 

Tenderness. — Neuralgia,  in  the  absence  of  neuritis,  causes 
little  or  no  tenderness  along  the  course  of  the  nerves,  nor  over  the 
site  of  the  brachial  plexus,  though  there  are  well-defined  tender 
areas  in  which  points  of  maximal  tenderness  are  located.  Accord- 
ing to  Dana,  these  areas  of  maximal  tenderness  do  not  always 
correspond  with  the  tender  points  of  Valleix.  It  is  common  for 
patients  to  rub  those  tender  areas  with  some  form  of  liniment  in 
the  endeavor  to  ease  the  pain.  It  is  needless  to  say  that  this  pro- 
cedure is  productive  only  of  irritation  and  inflammation  at  the 
site  of  the  rubbing,  without  any  alleviation  of  the  pain.  Others 
engage  masseurs,  who  put  the  patient  through  a  course  of  treat- 
ment, generally  with  a  negative  result,  though  in  some  cases  they 
irritate  the  nerves,  and  increase,  instead  of  decrease,  the  pain. 

The  tender  areas  are  located  on  the  anterior  and  posterior 
surface  of  the  arm  and  shoulder.  Those  on  the  anterior  surface 
are  found  over  the  outer  third  of  the  clavicle  and  infraclavicular 
fossa,  over  the  deltoid,  at  the  outer  surface  of  the  arm,  over  the 
inner  surface  of  the  arm  just  above  the  elbow,  over  the  middle  of 
the  forearm,  and  (one)  over  the  wrist  (Gowers).  On  the  pos- 
terior surface  the  areas  are  found  over  the  scapula  in  the  supra- 
spinatous  fossa,  over  the  posterior  margin  of  the  scapula,  over  the 
upper  surface  of  the  arm  where  the  arm  and  the  shoulder  join, 
over  the  middle  of  the  arm,  and  over  the  middle  part  of  the  fore- 
arm. The  areas  along  the  posterior  margin  of  the  scapula  are  in 
close  relation  with  the  points  of  tenderness  of  occipital  neuralgia. 
They  lie  over  the  second  and  third  cervical  spines.  They  are  also 
closely  related  to  the  points  of  tenderness  of  cervicobrachial  neu- 
ralgia, which  lie  over  the  first  or  second  dorsal  spines  (Trousseau), 
and  of  brachial  neuralgia,  whose  points  of  tenderness  lie  over 
the  third  and  fourth  dorsal  spines. 

Associated  symptoms  may  be  present,  but  they  are  not  com- 
mon unless  a  neuritis  is  present.     When  that  is  present  there  is 


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164     PAIN  IN  DISEASES  OF  THE  NERVES,  BRAIN,  AND  CORD 


generally  some  muscular  paralysis  and  atrophy.  At  first  the  elbow 
jerk  is  a  little  exaggerated,  and  then  becomes  decreased,  and  anes- 
thesia is  absent.  In  brachialgia  these  changes,  if  present  at  all, 
are  a  later  development.  In  the  early  stage  no  physical  change 
can  be  noticed  in  the  arm  except  a  slight  swelling  and  some  flabbi- 
ness  of  the  tissues. 

Circumflex  ]^euralgia. — Circumflex  neuralgia  is  more  com- 
mon than  one  would  naturally  suppose,  and  of  all  neuralgias  it  is 
probably  the  most  frequently  wrongly  diagnosed,  and  often  mis- 
taken for  rheuma- 
tism of  the  shoul- 
der joint.  From 
this  it  is  to  be  dis- 
tinguished by  the 
absence  of  swell- 
ing in  the  joint, 
the  more  or  less 
intermittent  pain, 
presence  of  exacer- 
bations, etc.  Per- 
verted sensations 
are  also  present, 
as  tingling,  burn- 
ing, and  numb- 
ness. Tenderness 
over  the  deltoid 
and  teres  muscles 
is  present,  and  is 
very  severe  over 
the  line  of  the  nerve.  The  causes  of  circumflex  neuralgia,  accord- 
ing to  Disna  (598),  are  toxic  materials  (as  arsenic),  infections 
(as  tuberculosis),  diabetes,  rheumatism,  gout,  draughts,  injury 
to  the  shoulder,  blows  across  the  deltoid  muscle,  fracture  of  the 
surgical  neck  of  the  humerus,  and  dislocation  of  the  shoulder 
joint. 

Intercostal  ISTeuralgia. — Intercostal  neuralgia  occurs,  as  a 


Fig.  55. — Method  of  Eliciting  the  Points  of 
Tenderness  in  Intercostal  Neuralgia. 


AFFECTIONS    OF    THE    NERVE    TERMINALS  165 

rule,  rather  suddenly,  and  comes  on  after  exposure  to  cold,  etc. 
It  appears  in  paroxysms,  which  are  very  severe  while  they  last, 
the  pain  seeming  to  extend  around  the  chest.  Any  exposure  to 
cold  excites  a  paroxysm.  Pressure  pain  over  the  nerve  is  present, 
and  it  is  specially  marked  (a)  near  the  spinous  process  of  the 
vertebra ;  (b)  near  the  mid-axillary  line ;  and  (c)  behind  the  left 
margin  of  the  sternum.  Herpes  zoster  is  frequently  confused  with 
this  condition.  The  pain  may  last  from  one  to  several  days,  then 
gradually  becomes  less  and  less  severe,  and  finally  disappears. 
Frequently  after  its  disappearance  a  feeling  of  soreness  remains. 
Pleurisy  without  effusion  is  often  confounded  with  intercostal 
neuralgia.  A  point  of  difference  is  that  in  intercostal  neuralgia 
the  pain  increases  when  the  patient  bends  over  toward  the  affected 
side,  while  in  pleurisy  the  pain  decreases  (Schepelman,  24b,  p. 
1078). 

Differential    Diagnosis    Between    Intercostal    Neuralgia 
AND  Pleurisy  (Schepelman) 

INTERCOSTAL    NEURALGIA  DRY    PLEURTSY 

Character  Sticking,    burning    or    lanci-       Sticking  and  lancinating,  but 

of  Pain —  nating — paroxysmal.  occurs  on  breathing. 

Radiation  Often  to  the  inner  side  of  the       None. 

of  Pain —  arm. 

Location  of  Pain — In  intercostal  spaces.  Over  an  infected  area  of  the 

pleura. 
Pressure  Points —  (a)  Near  to  the  vertebra  at       Over  the  infected  area  of  the 
the  back  of  origin  of  the  pleura, 

intercostal  nerves. 

(b)  Axillary  line. 

(c)  Sternal  line 

Pressure — ■  Touch  and  pressure  are  very  Painful  over  the  area  of  the 

painful    on    the    affected  diseased  pleura, 

nerves. 

Galvanization —      Reduction  of  the  pain.  No  change. 

Herpes —  Often  occurs.  None. 

Rubbing  Sounds —  Absent.  Present. 

{Friction  Fremitus) 

SS;'-  }  •  •  •  -Not  so  painful.  Very  painful. 

Neuritis  of  the  Caudal  Nerve  Roots. — Kennedy  and  Cals- 
berg  have  reported  cases  in  which  pain,  sharp,  shooting  and  burn- 
ing was  felt  almost  entirely  in  the  backs  of  the  thighs  and  in  the 
calves.  It  generally  begins  as  a  unilateral  pain,  but  after  the  lapse 
of  some  months  is  felt  in  both  legs.    The  leg  first  involved  remains 


166    PAIN  IN  DISEASES  OF  THE  NERVES,  BRAIN,  AND  CORD 

throughout  the  illness  more  affected  than  its  fellow.  There  is  also 
much  tingling  and  numbness,  sometimes  in  the  feet,  sometimes  in 
the  knees,  and  at  other  times  in  the  entire  lower  extremities.  An 
associated  symptom  is  atrophy  of  the  anterior  tibial  muscles. 

Sciatica. — By  many  sciatica  is  thought  to  be  a  neuritis,  while 
others  consider  it  a  form  of  reference  pain  from  some  lesion,  oc- 
curring along  the  course  of  the  sciatic  nerve.  In  some  cases  the 
sacroiliac  joint  becomes  diseased;  and  since  the  lumbo-sacral  nerve 
passes  over  it,  any  disturbance  of  the  joint  will  affect  the  nerve. 
Sometimes,  also,  a  spicule  of  bone  from  an  osteoarthritis  of  the 
spine  may  press  on  the  nerve.  Pressure  by  a  tuberculous  abscess 
will  also  cause  this  condition  (Adams,  603).  Sciatica  often  fol- 
lows a  fall  or  an  injury,  and  is  the  result  of  infections,  consti- 
pation, sudden  changes  of  temperature,  etc.  Pressure  on  the 
nerve  (relieved  by  an  elastic  stocking)  has  also  been  a  cause 
(Edinger).  Women  are  less  frequently  affected  than  men,  in  the 
proportion  of  one  to  four.  It  is  most  frequent  after  the  age  of 
forty,  and  up  to  sixty  years  of  age  (Duckworth,  604). 

The  Pain. — The  pain  is  constant,  with  severe  paroxysms, 
which  generally  occur  at  night.  x\t  first,  according  to  Climenko, 
there  is  an  uneasy  throbbing  sensation  in  the  dorsum  of  the  thigh 
with  some  tenderness  at  the  seat.  In  a  day  or  two  these  sensations 
develop  into  sticking,  boring,  tearing,  and  even  lightning-like  pains 
along  the  distribution  of  the  sciatic  nerve  and  its  divisions.  At  the 
time  of  the  paroxysms  the  pain  is  sharp  and  lancinating.  Between 
the  paroxysms  it  is  dull  and  aching.  Frequently  it  comes  on  after 
exposure  to  cold,  or  following  an  injury.  As  a  rule  it  does  not  last 
longer  than  a  few  months,  though  it  may  persist  for  a  j'ear.  Be- 
cause motion  increases  the  pain,  the  patient  tries  to  ease  the  weight 
on  the  affected  side,  and  holds  up  the  pelvis  toward  the  sound  side, 
thus  flexing  the  trunk  toward  the  diseased  side  and  producing  a 
static  scoliosis. 

Location  of  the  Pain. — The  pain  is  felt  principally  in  the 
back  of  the  thigh,  and  runs. down  the  leg,  following  the  course  of 
the  sciatic  nerve.  Sometimes  it  is  over  the  sacral  or  lumbar 
area.     Frequently,  on  motion,  pain  is  felt  at  the  sciatic  notch. 


AFFECTIONS  OF  THE  NERVE  TERMINALS 


167 


The  cause  of  this  pain  is  the  pressure  of  the  nerve  against  the  rim 
of  the  sciatic  notch  by  the  inflamed  and  contracting  pyriformis 
muscle   (Bashinger,  601).     The  tender  points   (Valleix's  points, 


Fig.  56. — Cutaneous  Distribution  Areas  of  the  Small  and  Greater 

Sciatic. 

SS= small  sciatic;  EP= external  popliteal;  PT=post  tibial;  S  — sciatic;  IS  = 
internal  saphenous;  EP  and  PT  are  branches  of  the  great  sciatic.  These 
drawings  are  composites  from  those  given  by  Head  and  Thompson  and 
represent  the  areas  in  which  sensation  was  lost  after  division  of  their 
respective  nerve  supply,  consequently  they  would  also  represent  the 
areas  in  which  pain  would  be  felt  in  any  painful  lesion  of  the  nerve. 
These  areas  correspond  rather  closely  with  those  given  by  McKenzie  (599). 


according  to  Edinger)  are  located:  (1)  over  the  anterior  superior 
spine  of  the  ilium;  (2)  in  the  center  of  the  posterior  surface  of 
the  thigh;  (3)  just  inferior  to  the  lower  margin  of  the  gluteus 
maximus;  (4)  in  the  middle  of  the  calf  of  the  leg;  (5)  under  the 


IGS     PAIN  IN  DISEASES  OF  THE  NERVES,  BRAIN,  AND  CORD 

head  of  the  fibula;  and  (6)  in  the  popliteal  space.  Dana  also 
gives  the  back  of  the  foot  and  the  sciatic  notch  as  points  of  ten- 
derness. In  some  cases  the  pain  is  referred,  and  it  is  found  in 
the  area  of  distribution  of  the  sciatic  nerve  (see  figure).  Bruce 
(502,  p.  511)  advances  an  original  idea  when  he  states  that 
sciatica  is  due  to  disease  of  the  hip  joint.  He  has  found  wasting 
of  the  gluteal  muscles  (59  per  cent.)  and  obliteration  of  the 
gluteal  folds  (30  per  cent.)  in  nearly  all  the  cases  which  he  has 
examined.  Lameness  was  also  most  constantly  present.  Diag- 
nostic of  sciatica  is  pain  running  up  the  back  of  the  thigh  when 
pressure  is  made  on  the  posterior  part  of  the  knee  with  the  leg 
extended  a  little  more  than  a  right  angle  (Dana,  from  Gowers). 
Kernig's  sign  is  that  hip  motions  are  free  as  long  as  the  knee  is 
flexed,  but  become  limited  if  the  leg  is  straightened  and  flexion 
of  the  thigh  is  attempted.  Sciatica  should  be  diagnosed  from 
hip-joint  disease,  disease  of  the  cord  (tumors  of  the  cauda  equina"). 


Fig.  57. — Method  of  Eliciting  Pain  in  Sciatica. 

new  growths  (sarcoma),  bone  formations,  etc.  Gordon  (608) 
reports  two  cases  of  tumor  of  the  sacrum  which  had  been  mistaken 
for  sciatica.  Tabes  has  sometimes  been  mistaken  for  sciatica,  but 
the  presence  of  the  knee  jerk  in  sciatica  will  exclude  tabes.  In 
relation  to  sciatica,  Faber  (616)  mentions  several  cases,  in  which, 
in  addition  to  the  sciatica,  there  was  also  present  a  well-marked 
degree  of  adiposa  dolorosa.     After  the  reduction  of  the  adipose 


AFFECTIONS  OF  THE  NERVE  TERMINALS 


169 


tissue,  the  patients  felt  verj  much  better.  In  cases  of  this  kind, 
patients  mav  have  at  the  same  time  well-developed  symptoms  of 
both  adiposa  dolorosa  and  sciatica,  and  the  one  should  not  be 
treated  to  ■  the  exclusion  of  the  other.  In  all  cases  of  sciatica 
examine  the  pelvis  carefully  (per  vagina  and  rectum)  and  the 
hip-joint  both  bimanually  and  by  the  X-ray. 

In  Figure  57  is  sho^\Ti  a  method  of  eliciting  pain  in  sciatica 
by  making  pressure  on  the  nerve  as  it  emerges  from  the  sciatic 
notch. 

Pla^tak  l^EUEALGiA. — Plantar  neuralgia  is  due  to  a  lesion 
of  the  plantar  nerve,  and  anesthesia  or  paresthesia  frequently  ac- 
companies the  pain.  In  the  accom- 
panying figure  the  area  of  distribu-  lat.  piaatar  i  n  s. 
tion   of  the   nerve   is   outlined,   and    Ext.  piantar  iv.  v, 

L,  IS. 

it    is    in    this    area    that    the    pain 
occurs. 

Morton's  neuralgia,  due  to  pres- 
sure on  the  digital  branch  of  the 
external  plantar  nerve,  is  found  in 
early  stages  of  flat-foot  disease. 

In  some  cases  of  typhoid  fever  the 
toes  become  very  tender.  This,  ac- 
cording to  McCrae  (607),  is  due  to 
a  local  neuritis.  It  closely  resembles 
a  plantar  neuralgia.  The  first  com- 
plaint of  the  joatient  is  of  pain  from 
pressure  of  the  bed-clothes. 

Sacral  or  Lumbar-cord  Neu- 
ralgia.— Sacral  or  lumbar-cord  neu- 
ralgia is  betrayed  by  pain  in  practically  the  same  regions  as 
Head  has  outlined  as  the  distribution  areas  of  the  different  cord 
zones.  In  Ivocher's  figures  the  boundaries  are,  as  a  rule,  held  to 
be  somewhat  too  high,  the  true  areas  in  reality  being  one  or  two 
zones  lower. 

It  is  useless  to  reiterate  what  has  been  said  in  regard  to  lumbar 
or  sacral  root  neuralgia,  because  the  symptoms  are  exactly  simila'- 


FiG.  58. — Distribution  of 
THE  Plantar  Nerves. 

The  plantar  nerves  are  branches 
of  the  tibial  which  is  a 
branch  of  the  sciatic  (modi- 
fied from  Cunningham's  An- 
atomy; also  from  Gerrish's 
Anatoni}') . 


170     PAIN  IN  DISEASES  OF  THE  NERVES,  BRAIN,  AND  CORD 

to  those  found  in  brachial  root  neuralgia,  to  which  the  reader  is 
referred.  With  this  reference,  and  by  the  aid  of  the  accompany- 
ing figures  (Head  zones;  and  Figs.  1889,  1890,  Toldt),  the  reader 
should  be  able  clearly  to  differentiate  this  condition. 

When  a  root  or  a  root  ganglion  is  involved,  a  continuous  area 
of  the  skin  is  ahvays  affected,  even  though  the  fibers  derived  from 
this  root  unite  with  others  to  form  a  plexu^.  These  regions  of  dis- 
tribution overlap  so  that  when  a  root  is  diseased,  sensation  (epi- 
critic)  is  not  completely  destroyed  over  the  entire  area  of  the  root 
distribution  (Tigcrstedt).  It  is  entirely  absent  only  in  a  central 
area.  It  increases  gradually  toward  the  periphery  until  it  be- 
comes normal  in  the  areas  of  distribution  of  the  unaffected  roots. 
This  border  zone  is  not  present,  as  a  rule,  for  protopathic  sensation. 
For  this  the  cord  zones  seem  to  be  more  definitely  marked.  There 
is  greater  overlapping  in  the  distribution  of  the  nerve  in  the 
peripheral  part  of  a  limb  than  in  the  proximal  part  (Buzzard, 
''Brain,"  Vol.  25,  p.  308).  This  is  due  to  a  spreading  out  of  the 
nerve  fibers  in  the  periphery  of  the  limb.  These  border  areas 
react  to  a  much  gi'eatcr  degree  than  normal  to  painful  stimuli,  but 
the  strength  of  the  stimulus  to  produce  a  reaction  must  be  much 
greater  than  that  applied  to  normal  skin. 

In  regard  to  loss  of  sensation,  Head  and  Sherren  say  that  "it 
would  seem  that  division  (disease)  of  the  posterior  roots  abolishes 
sensation  to  prick  over  an  area  larger  and  more  sharply  defined 
than  that  which  becomes  insensitive  to  light  touch.  Moreover,  this 
insensibility  to  prick  is  accompanied  by  an  inability  to  appreciate 
temperatures  below  15°  C  and  above  60°  C,  although  40°  C. 
and  23°  C.  may  appear  definitely  warm  and  cool."  In  lesions 
of  the  peripheral  nerves  the  opposite  is  the  case,  the  epicritic  sen- 
sation being  lost  in  a  larger  area  than  is  the  protopathic ;  i.e.,  the 
sensation  to  fine  touch  was  absent  in  a  larger  area  than  was  the 
sensation  to  prick  (Head  and  Sherren,  244,  pp.  310-311).  Buz- 
zard (613),  in  a  case  of  injury  to  the  cord  roots,  found  the  sensi- 
bility to  pain  and  temperature  abolished,  but  the  tactile  sensibility 
partially  retained.  When  sensation  returns,  the  first  to  recover  is 
the  sensibility  to  prick,  and  to  the  more  extreme  degrees  of  heat 


AFFECTIONS    OF    THE    NERVE    TERMINALS 


171 


and  cold  (Head  and  Sherren).  In  some  cases  lesions  of  the 
posterior  roots  are  present,  and  sensations  are  lost  without  the 
patient  heing  aware  of  their  absence. 

When  the  posterior  ganglia  are  affected,  herpes  generally  ac- 
companies the  neuralgia.  When  it  is  present,  a  copious  eruption 
of  vesicles  appears  over  the  affected  area.  These,  when  they  dry 
up  and  desquamate,  leave  a  brownish  sjiot.  The  pain  does  not 
disappear  upon  the  disappearance  of  the  eruption,  but  may  con- 
tinue for  some  time  longer.  A  diagnostic  sign  of  value  in  differ- 
entiating cord  lesions  from  root  or  nerve  lesions  is  the  dissociation 
of  sensation.  When  the  cord  is  diseased,  pain,  touch,  tempera- 
ture, etc.,  may  be  individually  or  collectively  abolished;  but  in 
nerve  lesions  they  are  always  collectively  abolished  (Sherren, 
612). 

The  following  is  a  differential  diagnosis,  compiled  chiefly  from 
Sherren : 


CoKD  Lesion. 
Loss  of  pain  perception. 


Temperature  sense  is  changed, 
so  that  (a)  sensibility  to  heat 
may  be  abolished  without  any 
change  in  respect  to  the  sensi- 
bility for  cold  (the  inverse 
may  be  the  case)  ;  (b)  all  dis- 
tinctions between  the  minor 
and  extreme  degrees  of  tem- 
perature are  lost ;  and  (c) 
"insensitiveness  may  be  pres- 
ent to  all  forms  of  heat  and 
cold,  the  lightest  touch  may 
be  felt,  and  discrimination  of 
the  points  of  a  pain  may  be 
present." 


Peripheral  LESIO^". 

Pain  produced  by  excessive 
pressure  as  long  as  there  is 
any  touch  sensation. 

All  sensations  are  affected,  but 
not  to  the  same  extent,  the 
epicritic  being  affected  in  a 
greater  area  than  is  the  proto- 
pathic  sensibility. 


172     PAIN  IN  DISEASES  OF  THE  NERVES,  BRAIN,  AND  CORD 


Cord  Lesion. 

Both  superficial  and  deep  touch 
are  usually  unaffected,  but 
when  absent  they  usually  dis- 
appear together. 

The  patient  may  have  touch  sen- 
sation, but  be  unable  to  appre- 
ciate pain,  heat  and  cold. 


Passive  movement  and  position 
of  the  limb  are  not  apparent 
to  the  patient. 

Spasticity  of  muscles  on  the 
same  side  below  the  level  of 
the  lesion. 

Paralysis  and  wasting  of  mus- 
cles at  level  of  the  lesion. 

Keflexes  having  origin  below 
the  level  of  the  lesion  are  in- 
creased. 

Pupillary  reflex  may  be  affected 
if  the  lesion  is  in  the  cervical 
cord,  on  account  of  affection 
of  the  cervical  sympathetic. 

Muscle  atrophy  may  not  occur. 


Peripheral  Lesion. 
Absent  in  a  peripheral  lesion. 


"Light  touches  over  the  distri- 
bution area  with  cotton  wool 
are  usually  not  appreciated, 
though  deep  touch  and  pres- 
sure evoke  a  response." 

Passive  movements  and  position 
of  the  limb  apparent. 


No  spasticity. 


Paralysis  of  the  muscles  sup- 
plied by  the  affected  nerve. 

Reflexes  originating  in  the  af- 
fected area  are  decreased. 

Pupillary  reflex  is  not  affected. 


Muscular  atrophy  of  the  muscles 
supplied  by  the  affected  nerve 
is  always  present 


CENTRAL  NERVOUS  SYSTEM^ 

The  discussion  of  diseases  of  the  central  nervous  system  re- 
quires a  recapitulation  of  the  normal  anatomical  relations,  which 
will  be  given,  as  briefly  as  possible,  in  the  following  paragraphs. 


1  Written  by  Dr.  Alfred  Neuman,  Vienna, 


CENTRAL  NERVOUS  SYSTEM  173 

It  will  be  entered  upon  here  only  so  far  as  appears  necessary  for 
the  understanding  of  the  subject. 

ANATOMY 

The  surface  of  the  brain  is  supplied  with  furrows  and  convo- 
lutions, which,  though  of  many  varieties,  show  a  certain  regularity 
through  which  it  is  possible  to  differentiate  them  in  every  case. 
A  few  of  them  have  special  importance,  and  will  be  more  minutely 
discussed. 

The  central  convolutions  on  the  convex  side  of  the  brain,  the 
paracentral  lobe,  and  the  median  wall  of  the  hemisphere  with  the 
adjacent  part  of  the  frontal  lobe,  represent  the  motor  region.  Far- 
thest below  is  the  center  for  the  facial  and  hypoglossus ;  in  the 
middle  is  found  the  center  or  centers  for  the  movements  of  the 
upper  extremity;  and  in  the  uppermost  third  those  for  the  move- 
ment of  the  lower  extremity  of  the  opposite  side  of  the  body. 
The  centers  innervating  the  musculature  for  the  act  of  eating, 
for  talking,  for  trunk  movements,  and  for  the  closure  of  the 
eyes,  are  connected  with  the  corresponding  muscles  of 
both  sides,  so  that  in  case  of  a  unilateral  destruction  of  a 
center,  the  ability  to  perform  these  movements  still  per- 
sists. The  speech  center  occupies  the  posterior  part  of  the 
third  frontal  convolution,  as  well  as  the  first  temporal  con- 
volution. In  right-handed  individuals  it  lies  in  the  left  hemi- 
sphere. In  the  third  frontal  convolution  occurs  the  transforma- 
tion of  ideas  into  words.  The  motor  speech  center  in  the  tem- 
poral convolution  is  the  seat  for  word  sounds  (sensory  speech 
center).  The  centers  for  the  sensation  coming  from  the  body  lie, 
apparently,  in  the  region  of  the  motor  centers,  and,  as  it  seems, 
are  practically  identical  with  them.  However,  the  entire  poste- 
rior central  convolution,  as  well  as  the  parietal  lobe,  evidently  be- 
longs to  the  sensory  sphere.  The  centers  for  vision  lie  in  the  oc- 
cipital lobes,  viz.,  in  the  fissure  calcarina  and  in  the  cuneus,  per- 
haps, also,  in  the  neighboring  adjacent  portions  of  the  lingual 
globe.  The  recollections  of  sensations  of  sight  (the  field  for  optit 
paemory)   are  said  to  lie  on  the  convexity  of  the  occipital  lobe, 


174     PAIN  IN  DISEASES  OF  THE  NERVES,  BRAIN,  AND  CORD 

The  olfactory  center  is  supposed  to  lie  in  the  gyrus  hippocampus 
and  uncinatus.  The  auditory  center  occupies  the  upper  convolu- 
tions of  the  temporal  lobe.  From  these  centers,  on  the  one  hand, 
pass  the  centrifugally  conducting  fibers  to  the  periphery;  on  the 
other  hand  the  centripetal  conducting  fibers  enter  them.  Of 
course,  it  is  neither  possible  nor  necessary  to  discuss  all  the  con- 
ducting tracts ;  only  the  two  most  important  ones  will  be  discussed 
here. 

Passing  inward  and  downward  from  the  motor  centers,  the 
motor  fibers  are  gathered  in  the  posterior  limb  of  the  internal 
capsule,  near  the  knee.  They  pass  then  into  the  brain  peduncle, 
and  from  here  the  central  portion  passes  through  the  pons  into 
the  medulla  oblongata,  Avhere  a  part  undergoes  decussation  and 
enters  the  lateral  column  of  the  spinal  cord,  from  whence  it  goes 
over  into  the  anterior  roots  of  the  peripheral  nerves.  The  smaller 
part,  non-decussated,  descends  in  the  anterior  column  of  the  spinal 
cord,  and  undergoes  partial  decussation  farther  below,  and  finally 
enters  the  anterior  roots. 

The  fibers  for  the  motor  nerves,  which  spring  from  regions 
lying  adjacent  to  each  other,  run  to  the  capsule  in  front  of  the 
pyramidal  tract,  decussate  in  the  pons  and  in  the  medulla,  and 
reach  the  corresponding  nuclei. 

The  course  of  the  sensory  conducting  fibers  is  more  complicated, 
but  it  shows  in  many  respects  a  resemblance  to  that  of  the  pyram- 
idal fibers.  These  sensory  fibers,  entering  through  the  posterior 
roots,  run  for  a  part  of  the  time  (uncrossed)  in  the  funiculus 
gracilis  and  cuneatus  to  their  nuclei,  also  to  the  nucleus  of  the 
funiculus  gracilis  and  the  nucleus  of  the  funiculi  cuneati  in  the 
posterior  surface  of  the  fourtli  ventricle.  From  here  they  pass 
through  the  fibers  of  the  arciformis  internis,  between  the  olives, 
to  the  opposite  side  (lemniscus  decussation),  which  lies  above  the 
pyramidal  decussation.  One  other  part  of  the  sensory  fibers  which 
ascends  in  the  ground  bundle  of  the  anterior  and  lateral  columns 
of  the  cord,  and  has  previously  crossed,  joins  with  the  first  ones, 
after  their  crossing,  and  then  again  enters  in  common  with  them 
and  passes  through  the  crest  of  the  peduncle  to  the  brain  cortex. 


CENTRAL  NERVOUS  SYSTEM  175 

on  the  way  undergoing,  in  the  optic  thalamus,  another  interrup- 
tion hj  relaying  cells.  Besides  this,  on  the  part  of  the  lemniscus 
tract  (the  median),  there  is  another  portion,  namely,  the  lateral 
lemniscus,  which  is  composed  of  the  fibers  of  the  acousticus  and 
the  sensory  fibers  of  the  cranial  nerves,  and  which  lies  more  later- 
ally. It  also  arises  in  the  upper  half  of  the  pons,  out  of  a  collec- 
tion of  ganglia  which  communicate  with  the  corresponding  sensory 
cranial  nerves,  and  passes,  partly  decussated,  into  the  corpora 
quadrigemina,  and  from  thence  to  the  cortex. 

The  pains  which  are  due  to  diseases  of  the  nervous  system  or 
its  sheath  are  localized,  on  the  one  hand,  in  the  head,  in  affections 
of  the  brain,  and  on  the  other  hand  in  the  back  and  the  extremi- 
ties in  diseases  of  the  spinal  cord.  Exceptions  to  this  general  rule 
occur.  Thus,  there  are  jDains  radiating  into  the  extremities  in 
aifections  of  the  sensory  tracts  in  the  brain  (Edinger)  and  head- 
ache in  spinal-cord  diseases  (tabes,  multiple  sclerosis).  Although 
these  exceptions  are  not  very  frequent,  yet  we  cannot  attribute 
every  headache  to  an  affection  of  the  brain  substance,  nor  every 
back  pain  to  an  affection  of  the  spinal  cord.  Both  symptoms  also 
belong  to  other  diseased  organs,  and  w^e  are  obliged  to  include  in 
our  discussion  those  forms  of  headache,  or  of  pain  in  the  back, 
which  are  caused  by  injuries  which  are  indirectly  elicited  or  pro- 
duced by  changes  in  the  substance  of  the  central  nervous  system 
or  their  sheaths  (through  the  circulation  or  by  reflex  means)  ;  for 
instance,  headache  in  anemia,  constipation,  abnormalities,  or  in 
refractive  errors  of  the  eye. 

ORIGIN    OF    HEADACHE 

!Row  we  should  first  ask  ourselves  where  the  sensations  desig- 
nated as  headaches  arise,  and  in  which  tissue  layer  they  are  local- 
ized. It  has  been  shown  by  clinical  observations  that  both  the 
brain  substance  and  all  its  sheaths  may  be  the  seat  of  the  pain. 
Concerning  the  membranes,  it  is  seldom  questioned  that  pains  can 
originate  therein;  indeed,  frequently  they  have  been  considered 
as  the  only  bearers  of  headache,  since  they  are  supplied  with  cere- 
brospinal nerve  fibers,  which  seem  alone  to  be  capable  of  pain  con- 


176    PAIN  IN  DISEASES  OF  THE  NERVES,  BRAIN,  AND  CORD 

duction.  The  cortical  origin  of  headaches,  on  the  ground  of  the 
observations  of  Lennander,  would  be  declared  impossible,  because 
of  his  observation,  by  operation,  that  the  brain  cortex  may  be 
sectioned  without  the  patient  feeling  anything.  Because  of  this, 
all  intracranial  headaches  were  attributed  to  irritation  of  the  dura 
mater.  Xothnagel  objected  that  the  mechanical  irritation  em- 
ployed on  the  brain  was  not  sufficient  to  produce  a  reaction  be- 
cause another  sort  of  irritation  (toxic,  infectious)  was  needed  to 
produce  pain,  as  the  headaches  from  poisoning,  infectious  diseases, 
and  anemia  prove.  L.  R.  Miiller  remarks,  further,  that  symptoms 
of  loss  of  function  which  accompany  migraine,  as  the  shrinking  of 
the  field  of  vision,  prove  that  certain  parts  of  the  brain  are  func- 
tionless  for  a  short  time.  The  observations  of  Oppenheim  also 
speak  in  a  very  instructive  way,  opposing  the  view  that  only  the 
dura  mater  can  be  looked  upon  as  a  source  of  pain,  be  it  the  re- 
sult of  direct  or  indirect  irritation,  through  the  intervention  of 
brain  pressure.  The  dura  mater  beneath  the  occipital  bone  is 
painful  to  irritation  (Braun),  but  the  dura  beneath  the  frontal 
bone  is  not  painful  (Xystrom),  and  under  the  temporal  bone  has 
no  sensation  (Lennander).     (Keen's  System,  p.  1048). 

Before  it  can  be  certain  that  pain  which  is  felt  as  headache 
may  arise  in  the  brain  substance  itself,  we  must  know  the  nerves 
which  conduct  these  painful  stimuli  to  the  cortex.  The  only  per- 
ipheral nerves  known  to  be  present  in  the  brain  are  of  the  sympa- 
thetic system.  If  it  could  be  shown  that  these  fibers  are  able  to 
carry  stimuli  in  a  centripetal  direction,  we  would  be  justified  in 
ascribing  to  the  brain  substance  itself  the  power  of  originating 
painful  stimuli.  The  circumstances  are  similar  in  regard  to  the 
sensibility  of  the  abdominal  organs.  Here,  also,  are  found  nerves, 
which,  only  with  the  vagus  or  with  the  sympathetic,  enter  into  the 
viscera.  To  both,  only  the  motor  functions  were  ascribed,  there- 
fore it  was  concluded  that  the  viscera  possess  no  special  sensibility. 

However,  it  has  been  demonstrated  that  the  sympathetic  nerves 
carry  sensory  fibers  which  convey  irritations  from  the  viscera  to 
the  central  nervous  system  (Neuman) ;  and  this  removes  the  most 
important  objection  to  the  acceptance  of  the  idea  that  each  organ 


CENTRAL  NERVOUS  SYSTEM  177 

possesses  its  own  sensibility.  The  fact  that  the  cerebral  cortex  is 
insensitive  to  the  touch  of  the  fingers,  or  of  instruments,  only  goes 
to  prove  that  it  is  insensitive  save  to  these  types  of  stimuli,  which 
never  occur  normally.  Just  as  the  eye  receptors  act  for  light 
only,  so  there  are  probably  receptors  in  the  brain  tissues  which 
react  only  to  special  forms  of  stimuli.  Just  what  these  are  is  not 
as  yet  definitely  known.  The  further  conduction  of  the  irritation 
may  then  be  described  as  being  through  the  rami  communicans  into 
the  posterior  roots  and  then  through  one  of  the  above-described 
sensory  tracts  over  the  cord  back  again  to  the  cortical  brain  sub- 
stance. The  conduction  of  the  painful  irritation  from  the  cover- 
ings in  diseases  of  the  meninges,  of  the  cranium,  of  the  aponeu- 
roses, or  of  the  skin  is  over  the  trigeminus  to  the  terminal  cells  of 
the  same  in  the  mid-brain  ;  from  there  to  the  corpora  quadrigemina, 
to  the  thalamus,  and  finally  to  the  brain  cortex ;  in  a  similar  way, 
by  the  upper  cervical  nerves  through  the  median  portion  of  the 
lemniscus  (Edinger). 

Headache  also  appears  as  a  symptom  of  disease  of  the  brain 
substance  and  the  meninges,  and  in  diseases  which  certainly 
have  nothing  to  do  with  these  organs.  As  an  example  of  the  for- 
mer may  be  mentioned  the  headaches  of  brain  tumor  or  of  menin- 
gitis ;  as  an  example  of  the  latter,  the  so-called  rheumatic  or  indu- 
rative headache  may  be  mentioned.  ISTot  only  have  we  to  con- 
sider diseases  of  an  organic  nature,  but  also  those  in  which  purely 
chemical  substances  cause  molecular  alterations,  and  thus,  perhaps, 
cause  headaches.  Uremia,  the  different  metal  poisonings,  or  the 
infectious  diseases  are  examples.  Here,  also,  belong  the  headaches 
of  anemia,  of  congestive  states,  and  possibly  of  migraine. -"^ 

In  a  similar  manner,  also,  in  the  headaches  of  neurasthenia 
or  of  hysteria,  we  must  think  of  a  hitherto  undemonstrated  change 
in  the  central  nervous  system.  The  elicitation  of  pain  through 
mighty  efforts,  irritation  or  fright,  as  well  as  some  accompanying 
disturbances  (for  instance,  dizziness),  can  hardly  permit  of  an- 
other explanation. 

If  we  would,  with  the  help  of  headaches,  try  to  arrive  at  a 

'This  as  yet  has  not  been  demonstrated.     For  another  view,  see  pp.  189  and  190. 


178     PAIN  IN  DISEASES  OF  THE  NERVES,  BRAIN,  AND  CORD 

diagnosis  of  diseases  of  the  brain  and  its  membranes,  we  mnst 
determine  first  whether  they  do  not  also  occur  in  other  dis- 
eases, and,  second,  whether  they  possess  certain  special  peculiari- 
ties which  would  be  characteristic  of  different-diseases  of  the  brain 
or  of  the  brain  membranes.  Unfortunately,  we  have  no  such  cri- 
teria. Neither  are  headaches  limited  to  diseases  of  the  central 
nervous  system ;  nor  are  they  of  as  many  forms  as  their  causes  are 
numerous.  One  can  certainly  say  that  there  is  no  form  of  head- 
ache which  would  be  pathognomonic  for  a  certain  disease,  with  the 
single  exception,  possibly,  of  a  luetic  headache.  We  must  not  per- 
mit ourselves,  in  making  a  diagnosis,  to  be  guided  by  the  character 
of  the  headache  alone,  but  must  utilize  the  other  symptoms.  Nev- 
ertheless, in  the  character  of  the  headache  there  are  several  pe- 
culiarities, which,  if  they  do  not  speak  for  a  certain  disease,  may 
still  give  a  hint  as  to  the  nature  of  the  trouble.  Since,  here,  only 
those  forms  of  head  })ain  come  into  question  which  are  connected, 
first  of  all,  with  diseases  of  the  brain,  or  its  membranes,  all  other 
kinds  of  j)ain  belonging  to  the  symptom  complex  of  other  diseases 
will  be  excluded. 

Should  headache  be  present,  w-e  must,  in  our  diagnostic  in- 
vestigation, first  search  for  disease  of  the  outer  coverings  of  the 
central  organ ;  that  is,  of  the  bony  skull,  of  the  aponeurotic  layer, 
of  the  scalp  muscle,  and  of  the  scalp  itself.  These  are  treated  in 
Chapter  XIV.  Should  these  be  excluded  the  brain  and  its  cover- 
ing should  next  be  examined. 

HEADACHE    IN    DISEASE    OF    THE    BEAIN    AND    MENINGES 

Those  diseases  of  the  brain  and  the  meninges  in  which  head- 
ache forms  an  essential  part  of  the  symptom  complex  now  will 
be  described ;  and  in  conclusion  an  analysis  of  these  headaches  will 
be  given. 

First  of  all  let  us  remember  that  not  all  pathological  changes 
of  the  central  nervous  system  are  accompanied  by  pain,  and  gi-oss 
lesions  of  the  brain  are  found  (post  mortem)  without  the  patient 
having  complained  of  headache.  Therefore,  an  extensive  dis- 
turbance of  the  brain  may  occur,  as  in  cerebral  hemorrhage,  with- 


CENTRAL  NERVOUS  SYSTEM  179 

out  tlie  patient  making  any  complaint.  Even  laceration  may 
occur  so  slowly  that  the  patient  either  does  not  lose  consciousness 
or  does  not  at  once  become  unconscious.  The  same  is  the  case  in 
brain-softening,  in  encephalitis,  in  infantile  cerebral  palsy,  in 
general  paresis,  etc.  ISTevertheless,  headaches  are  also  found  in 
the  course  of  these  diseases,  either  as  a  prodromal  sign,  as  in 
hemorrhage,  or  in  the  later  stages ;  but  they  are  not  characteristic 
of  the  disease. 

In  other  diseases,  however,  headache  forms  an  important  symp- 
tom. Here  must  be  included  pachymeningitis  interna,  leptomen- 
ingitis, brain-abscess,  brain  tumor,  aneurysm  of  brain  arteries, 
syphilitic  diseases  of  the  brain  and  the  meninges,  migraine,  neuras- 
thenia, hysteria,  and  circulation  disturbances  in  the  brain.  We 
shall  not  discuss  the  latter. 

Pachymeningitis  Interna  Hsemorrhagica  (Hematoma  of  the 
Dura  Mat'cr). — From  a  pathological,  anatomical  standpoint  we 
have  to  deal  with  the  formation  of  a  fibrinous  membrane  on  the 
inner  surface  of  the  dura  mater,  into  which  there  occur  from 
time  to  time  smaller  or  larger  hemorrhages.  Headache  may  pre- 
cede or  follow  a  developing  coma,  or,  if  there  is  no  coma,  the 
pain  in  the  head  may  be  the  chief  symptom  of  the  disease. 
It  may  be  associated  with  nausea  and  vomiting.  Generally  the 
pain  is  very  intense.  It  may  be  felt  as  a  circumscribed  area,  and 
then  sensitiveness  to  percussion,  circumscribed,  unilateral,  or  dif- 
fuse, is  present.  When  the  hematoma  is  located  on  the  convexity, 
the  pain  on  the  diseased  side  frequently  predominates.  When 
the  hematoma  is  localized  at  the  base  of  the  skull  trigeminal  neu- 
ralgia occurs,  with  other  symptoms  due  to  pressure  upon  the 
cranial  nerves.  The  remaining  symptom-picture  of  pachymen- 
ingitis is  not  at  all  characteristic.  The  etiology  (alcoholism,  in- 
fectious diseases,  trauma,  general  paresis,  senility,  lues,  and  blood 
diseases,  pernicious  anemia,  leukemia  and  scorbutus)  is,  above  all, 
important.  In  classic  cases  an  irritative  stage,  wdth  delirium, 
precedes,  and  this  is  followed  by  the  attack  with  coma,  during 
which  signs  of  increased  brain  pressure  can  be  demonstrated. 
There  are  slowing  and  irregularity  of  the  pulse^  changed  breatL 


180     PAIN  IN  DISEASES  OF  THE  NERVES,  BRAIN,  AND  CORD 

ing,  vomiting,  contracted,  sluggish  or  nonreacting  pupils,  choked 
disc,  general  crami:)s,  bilateral  deviation,  etc.  (see  page  271). 

Symptoms  which  depend  upon  the  location  of  the  hemorrhage 
are  hemiplegias,  monoplegias,  and  unilateral  and  disseminated 
twitchings.  The  gradual  increase  and  frequent  change  of  the  phe- 
nomena, with  remissions  and  recurrences,  are  considered  a  charac- 
teristic. Hyperidrosis  and  elevation  of  temperature  to  41°  C. 
(105,4°  F.)  frequently  occur. 

Leptomeningitis  Purulenta. — Here  there  is  an  infiltration  of 
the  pia  mater,  especially  on  the  convexity.  This  is  at  first  serous 
and  later  purulent.  There  is  also  a  serous  infiltration  of  the 
superficial  layers  of  the  cortex.  In  the  tuberculous  form  a  gela- 
tinous, rarely  purulent  exudate  first  spreads  on  the  base  between 
the  brain  and  the  peduncles  and  extends  from  there  in  all  direc- 
tions, especially  in  the  sulci,  reaching  a  marked  degree,  however, 
only  on  the  convexity.  Headache  is  so  characteristic  in  this  dis- 
order that  one  should  not  make  a  positive  diagnosis  if  headache 
is  absent.  It  is  extremely  severe,  mostly  continuous,  but  pa- 
roxysmally  increasing.  The  headache  is,  as  a  rule,  located  (by 
the  patient)  in  the  entire  skull,  sometimes  more  in  the  forehead 
or  in  the  occiput.  The  patient  manifests  signs  of  pain,  even  in 
coma,  in  spite  of  the  deepest  stupor.  He  grasps  his  head,  and  at 
times  cries  out  loudly,  especially,  however,  if  one  tries  to  move 
the  head. 

In  tuberculous  meningitis  the  pain  in  the  beginning  has  a  dif- 
ferent character.  It  occurs  only  temporarily,  is  not  so  great  in 
intensity,  and  only  later  reaches  the  great  severity  just  men- 
tioned. Gradually  there  appear  disturbances  of  the  consciousness, 
delirium,  and  eventually  coma.  Stiffness  of  the  neck  (the  head 
being  drawn  backward),  stiffness  of  the  muscles  of  the  back,  and 
boat-like  retraction  of  the  belly  occur.  Hyperesthesia  of  the  skin 
and  the  muscles,  restlessness,  and  jactitations  are  characteristic. 
Not  uncommonly  we  find  unilateral  convulsion&,  and^  less  fre- 
quently, general  ones.  The  patients  conspicuously  and  rapidly 
become  emaciated.  In  extensive  involvement  of  the  base  of  th^^ 
brain,  involvement  of  the  cranial  nerves  occurs,  the  oculomotorius. 


CENTRAL  NERVOUS  SYSTEM  181 

the  optic  and  also  the  acoustic  being  especially  implicated.  The 
fundus  of  the  eye  often  shows  the  signs  of  neuritis.  The  tendon 
reflexes,  which  may  be  increased  at  first,  are  later  usually  lost, 
as  are  also  the  skin  reflexes.  Paralysis  of  the  bladder  and  the 
rectum  occurs  only  just  preceding  death. 

Chronic  Anemia  of  the  Brain  (Chlorosis,  Pernicious  Anemia, 
Leukemia,  etc.). — The  headache  in  these  diseases  is  usually  not 
very  severe,  often  consisting  only  in  hyperesthesia  of  the  head. 
It  can  be  recognized,  sometimes,  by  the  fact  that  it  grows  worse 
"when  the  patient  is  in  an  upright  position,  and  decreases  when 
he  lies  down.  Other  signs  due  to  anemia  of  the  brain  are  the 
occurrence  of  fatigue,  both  mental  and  physical,  after  a  small 
amount  of  work.  Drowsiness,  humming  in  the  ears,  stars  before 
the  eyes,  vertigo,  and  an  apathetic  state  may  be  present.  All 
these  conditions  improve  when  the  patient  lies  down  (see  page 
272). 

Hyperemia  of  the  Brain. — Congestions  which  consist  of  a  sud- 
den aiflux  of  blood  to  the  head  cause  pressure  and  sometimes 
pain,  which  increases  with  the  pulse  beat.  Other  symptoms  con- 
sist of  a  feeling  of  heat,  of  throbbing  in  the  face,  vertigo,  and 
disturbance  of  consciousness.  These  attacks,  however,  usually 
last  only  for  a  few  minutes,  sometimes  an  hour,  and,  in  rare 
cases,  several  hours.  The  headache  in  venous  congestions  of  the 
brain,  ear  lesions,  struma,  etc.,  is  made  worse  by  coughing  and 
sneezing,  as  well  as  by  the  patient  assuming  the  horizontal  posi- 
tion, especially  with  the  head  drooping.  The  rest  of  the  symp- 
toms are  not  unlike  those  in  chronic  anemia,  i.e.,  apathy,  drowsi- 
ness, vertigo,  and  slight  mental  confusion. 

Brain  abscess  originates  from  a  suppuration  transmitted  from 
the  skull.  It  may  be  of  traumatic  or  otitic  origin,  or  may  arise 
from  remote  organs.  In  regard  to  the  latter,  a  lung  abscess,  lung 
gangrene,  or  a  pyemia  may  form  the  primary  starting  point. 
Headache  is  one  of  the  earliest  and  most  constant  symptoms  of 
brain  abscess.  It  increases,  especially  during  the  development 
and  the  growth  of  the  pus  focus,  to  such  a  high  degree  that  the 
patient  constantly  groans  and  behaves  like  a  maniac.    In  the  latent 


182     PAIN  IN  DISEASES  OF  THE  NERVES,  BRAIN,  AND  CORD 

stage  the  pain  may  be  slight.  These  paroxysms  of  pain  often  last 
only  for  a  few  hours ;  sometimes,  however,  they  persist  for  days. 
The  pain  is  of  a  boring,  throbbing  character,,  mostly  dull,  either 
spread  over  the  whole  head,  or  is  more  severe  on  one  side,  prin- 
cipally on  that  which  is  the  seat  of  the  abscess.  However,  the 
localization  of  the  pain  does  not  always  correspond  to  that  of  the 
focus.  An  abscess  of  the  cerebellum,  for  instance,  may  cause 
frontal  headache.  A  circumscribed  area  of  sensitiveness,  on  per- 
cussion, furnishes  a  much  more  important  clew  to  the  localization 
of  the  focus.  Coughing,  sneezing,  stooping,  as  well  as  fever, 
make  the  headache  worse.  Other  symptoms  of  brain  abscess  due 
to  the  suppuration,  are  elevation  of  temperature,  which  does  not 
show  any  characteristic  course,  and  the  not  very  infrequent  chill. 
Retardation  or  irregularity  of  the  pulse,  changed  breathing,  optic 
neuritis  (which  occurs  here  more  frequently  than  choked  disc, 
and,  indeed,  more  frequently  on  the  same  side  as  the  focus),  gen- 
eral convulsions  and  mental  disturbances,  chiefly  in  the  form  of 
stupor,  depression,  delirium,  and  eventually  coma  are  later  symp- 
toms.    Rapid  emaciation  is  often  very  conspicuous. 

Brain  Tumor.- — Headache  is  one  of  the  most  frequent  signs 
of  this  disease.  In  accordance  wath  the  gradual  growth  of  the 
tumor,  the  pain  is  moderate  in  the  beginning  and  variable  in  its 
intensity.  Later  it  becomes  very  severe,  but  still  sliows  exacer- 
bations, w^hich  occur  generally  in  the  morning.  They  may  be 
partly  spontaneous,  and  partly  due  to  an  increase  of  blood  pres- 
sure from  pressing,  coughing,  sneezing,  stooping,  etc.  During 
such  paroxysms  the  patient  may  either  lie  in  bed,  gi-oaning,  often 
perfectly  apathetic,  or  he  may  run  about  in  the  room,  pushing 
and  knocking  his  head  against  the  wall,  and  behaving  like  a 
maniac.  Stupor  that  occurs  in  the  later  stage  dims  the  severity ; 
yet  even  then  one  observes  that  the  expression  of  the  face  is  dis- 
torted, and  the  seizing  of  the  head  by  the  hands  proves  the  con- 
tinuance of  pain.  The  pain  is,  as  a  rule,  diffused  over  the  entire 
head ;  sometimes  it  is  unilateral,  more  in  the  occipital,  or  more 
in  the  frontal  region.  Sometimes  the  localization  depends  ujjon 
the  position  of  the  tumor,  as  tumors  of  the  posterior  cranial  fossa, 


CENTEAL  NERVOUS  SYSTEM  183 

for  the  most  part,  cause  occipital  headache,  which  may  radiate 
into  the  shoulders.  One  must,  however,  not  depend  upon  this 
entirely.  More  stress  should  be  laid  ujion  the  circumscribed 
sensitiveness  on  percussion,  which,  however,  does  not  regularly 
occur,  but  only  when  the  tumor  lies  quite  superficial. 

Trigeminal  neuralgia,  especially  of  the  first  branch,  is  ob- 
served in  tumors  of  the  chiasma,  cerebello-pontine  angle,  and  pons, 
and  may  later  be  followed  by  loss  of  function  of  the  nerve.  Signs 
of  pressure  on  the  optic  nerve  are  rarely  lacking.  Papilledema 
(choked  disc)  is  seldom  missed.  It  may  be  absent  in  tumors  of 
the  central  convolutions,  and  of  the  first  and  second  frontal  con- 
volutions, but  it  is  almost  never  present  when  foci  are  in  the  pons. 
Otherwise,  however,  choked  disc,  or  its  forerunner,  optic  neuritis, 
is  one  of  the  cardinal  symptoms.  It  is  mostly  double  sided,  fre- 
quently more  intense  on  the  affected  side.  l\ot  less  important  are 
the  changes  of  intelligence  and  of  the  psyche.  The  patients  think, 
speak  and  act  more  heavily.  Soon  they  become  stupid  and  drowsy. 
They  fall  asleep  while  they  are  still  speaking,  or  in  the  midst  of 
a  meal.  At  such  times  they  pass  feces  and  urine  involuntarily. 
Delusional  ideas,  ideas  of  persecution,  and  finally  delirium  may 
be  present.  Very  frequently  vomiting  (of  a  cerebral  type)  oc- 
curs, with  retardation  of  tlie  pulse,  which  may  here  assume  a  high 
degree,  and,  after  some  time,  usually  passes  into  pulse  accelera- 
tion (vagus  paralysis).  Giddiness  is  frequently  complained  of. 
It  has  not,  however,  been  accompanied  by  rotatory  nystagmus, 
which  occurs  principally  in  tumors  of  the  cerebellum.  Convul- 
sions and  loss  of  consciousness  occur  paroxysmally,  together  or 
separately.  Parallel  with  these  general  symptoms  are  the  so- 
called  focal  symptoms.  By  direct  focal  symptoms  we  mean  those 
phenomena  which  are  the  result  of  pressure  on  that  area  of  the 
brain  in  wliich  the  new  gTowth  develops. 

Focal  Symptoms  of  the  Motor  Region, — Here  are  found 
the  results  of  irritation,  paresthesias  and  spasms,  which  are  fol- 
lowed later  by  paralysis.  These  three  phenomena  generally  begin 
in  one  particular  place,  and  then  spread  over  the  neighboring 
areas,  for  the  most  part  in  regular  order  (Jacksonian  fits).     The 


1S4     PAIN  IN  DISEASES  OF  THE  NERVES,  BRAIN,  AND  CORD 

order  in  which  the  individual  groups  are  affected  is  a  regular 
one,  and  extends  from  center  to  center,  beginning,  for  instance, 
in  the  right  foot,  and  extending  to  the  knee,  hip,  shoulder,  elbow, 
hand,  and  distribution  area  of  the  facial  nerve.  Consciousness 
is  intact,  at  first,  and  only  later  becomes  cloudy  in  attacks  of 
greater  intensity  and  longer  duration.  Correct  observation  of  the 
muscle  groups  initially  involved  is  of  importance  for  the  localiza- 
tion of  the  tumor. 

As  a  sequence  of  such  a  spasmodic  seizure,  but  also  unaccom- 
panied by  a  seizure,  paralyses  arise,  which,  in  the  beginning,  are 
transient,  but  which  later  become  permanent,  and  attack  (like 
cortical  epilepsy),  little  by  little,  wider  areas,  imtil  finally  they 
present  the  complete  picture  of  a  hemiplegia,  with  all  its  char- 
acteristics, namely,  increase  of  the  tendon  reflexes,  spasms,  ab- 
sence of  skin  reflexes,  Babinski,  clonus,  etc. 

Tumors  of  the  frontal  lobe  produce  motor  aphasia  if  they 
lie  in  the  left  inferior  frontal  convolution.  In  tumors  of  the  left 
second  frontal  convolution  one  sometimes  sees,  as  a  result  of 
the  disturbances  of  the  innervation  of  the  muscles  of  the  buttock, 
uncertainty  in  walking  and  standing,  and  in  turning  toward  the 
crossed  side.  As  a  remote  effect  upon  the  motor  region,  Jack- 
sonian  epilepsy  may  occur.  When  the  tumor  lies  in  the  temporal 
lobe,  disturbances  of  hearing,  such  as  buzzing  and  whistling,  may 
occur.  There  may,  also,  be  disturbances  of  smell  and  taste. 
Finally,  tumors  of  the  left  first  temporal  convolution  produce 
word-deafness,  memory  aphasia  and  paraphasia.  Here,  as  a  dis- 
tant result,  are  observed  Jacksonian  epilepsy;  and  further,  from 
the  action  on  the  occipital  lobe,  crossed  hemianopsia,  hemianes- 
thesia, and  hemiplegia. 

Tumors  of  the  parietal  lobe  give  rise  to  little  that  is  char- 
acteristic (disturbances  of  muscle  sense,  crossed  hemiataxia).  In 
fact,  as  a  rule,  they  produce  only  distant  effects,  by  pressure 
upon  the  motor  region  (Jacksonian  spasms),  or  on  the  occipital 
(hemianopsia),  etc. 

Still  more  uncertain  is  the  diagnosis  of  tumors  of  the  cor- 
pus CALLOSUM,  which,  according  to  Ziehen,  have  paraparesis  as 


CENTRAL  NERVOUS  SYSTEM  185 

the  only  sign  of  any  value.  Apraxia  is  often  present  in  tumors  of 
this   region. 

Tumors  of  the  CE^^TRAL  gaxgliox  characterize  themselves 
by  disturbance  of  the  inner  capsule.  Therefore,  they  cause  hemi- 
plegia, which  gradually  arises  if  more  of  the  anterior  part  of 
the  capsule  is  affected,  and  hemianesthesia  if  more  of  the  posterior 
part  is  affected.  Hemichoreas,  hemianesthesia,  and  unilateral 
tremors  may  result. 

When  the  corpora  quadeigemina  are  the  seat  of  the  tumor, 
sight  disturbances,  hearing  disturbances,  and  double-sided 
paralysis  of  the  eye  muscles  of  a  muscular  character  form  the 
clinical  picture.  With  the  disease,  also,  come  disturbances  of 
equilibrium  on  walking  and  on  standing. 

Tumors  of  the  pedunculi  cerebri  produce  paralysis  of  the 
oculomotor  of  the  same  side,  and  of  the  extremities  of  the  oppo- 
site side  (hemiplegia  alterans  superior),  oculomotor  paralysis, 
with  tremor,  similar  to  that  in  paralysis  agitans. 

If  the  CEREBELLUM  is  the  seat  of  the  tumor,  this  can  be 
recognized,  in  most  cases,  by  a  few  important  signs.  The  most 
characteristic  is  cerebellar  ataxia.  The  patient  sways  from  one 
side  to  the  other.  Frequently,  also,  he  complains  of  a  genuine 
dizziness,  in  which  objects  seem  to  be  moving  around  him,  espe- 
cially upon  sitting  up.  With  this  dizziness  nystagmus  is  fre- 
quently combined.  Vomiting  is  very  common.  It  is  also  an  im- 
portant symptom  that  the  headache  is  localized,  especially  in  the 
occipital  region,  possible  in  the  nape  of  the  neck,  and  that  the 
choked  disc,  which  is  mostly  bilateral,  is  seldom  absent.  Along 
with  this  are  opisthotonic  and  tetanic  contraction  of  the  muscula- 
ture of  the  neck.  As  indirect  local  symptoms,  the  affections  of  the 
different  cranial  nerves,  of  the  pyramidal  tract  (paraparesis, 
crossed  hemiparesis,  intentional  tremor)  and  also  the  occurrence 
of  hydrocephalus  interna  must  be  considered. 

Tumors  of  the  poxs  show  slight  development  of  general 
symptoms,  and  the  absence  of  a  choked  disc  almost  as  the  rule. 
The  most  classic  symptom  is  the  hemiplegia  alterans  inferior. 
There  is  paralysis  of  the  extremities  of  one  side,  with  paralysis 


186     PAIN  IN  DISEASES  OF  THE  NERVES,  BRAIN,  AND  CORD 

of  the  facial,  trigeminus,  or  abdiicens,  of  the  other  side,  in  which 
case,  of  course,  all  three  of  the  above-mentioned  cranial  nerves 
may  be  affected.  Very  frequently,  before  the  paralysis,  very 
severe  attacks  of  trigeminal  neuralgia  occur.  Further,  associated 
eye-muscle  paralysis  of  the  right  rectus  internus  on  the  side  of 
the  tumor  must  be  mentioned ;  also  in  right-sided  paralysis  there 
is  a  simultaneous  disturbance  of  hearing,  through  pressure  on  the 
acoustic  nerve  at  its  place  of  origin. 

Tumors  of  the  medulla  may  run  a  symptomless  course,  but 
when  they  produce  symptoms  they  are  similar  to  those  of  tumors 
of  the  pons,  with  the  exception  that  they  injure  deeper-lying 
cranial  nerves,  namely,  the  eighth  and  twelfth,  causing  disturb- 
ances of  hearing,  speech  and  deglutition,  as  well  as  paralysis  of 
the  extremity  on  the  other  side,  singultus,  diabetes  insipidus, 
breathing  changes,  etc. 

If  the  tumor  is  seated  in  the  thied  ventricle,  drowsiness 
and  change  of  intelligence  are  usually  prominent. 

Tumors  of  the  base  of  the  brain  give  rise  to  few  general 
symptoms.  According  to  Oppenheim,  choked  disc  and  vomiting 
frequently  fail.  Pain,  on  pressure,  occurs  in  the  bones  which  are 
in  relation  to  the  base  of  the  brain.  Bleeding  from  the  nose  and 
pharyngeal  cavities  also  occurs ;  and,  above  all,  is  to  be  considered 
the  involvement  of  brain  nerves  in  a  certain  combination  corre- 
sponding to  their  topographical  arrangement. 

Tumors  of  the  hypophysis  also  produce  few  general  symp- 
toms. Here,  also,  choked  disc  is  frequently  absent,  and  headache 
may  be  very  slight.  On  the  other  hand,  the  eye  symptoms  (bi- 
temporal hemianopsia,  amaurosis,  eye-muscle  paralysis,  exoph- 
thalmos) and  certain  disturbances  in  development  (hypoplasia  of 
the  genitalia,  feminine  habitus),  as  well  as  adipositus  universalis 
and  myxedematous  skin,  form  the  most  striking  symptoms. 

Tumors  of  the  posterior  cranial  fossa  often  begin  with 
humming  in  the  ears,  difficult  hearing  and  disturbances  of  equi- 
librium. Associated  with  these  is  irritation  or  paralysis  of  the 
trigeminus,  with  absence  of  the  corneal  reflex  (Oppenheim).  In 
relation  to  this,   as  a  result  of  the  pressure  on  the  surrounding 


CENTRAL  NERVOUS  SYSTEM  187 

region,  cerebellar  ataxia,  nystagmus  and  sight  paralysis  (Oppen- 
heim)  occur.  The  patient  complains  of  occipital  and  frontal 
headache  and  vomiting.  Objectively,  one  very  frequently  finds 
choked  disc  and  localized  sensibility  on  percussion. 

Aneurysm  of  the  Brain  Arteries.- — Here  the  headache  is  also 
one  of  the  general  symptoms.  It  is  generally  described  as  throb- 
bing, and  may  be  half-sided,  as  in  hemicrania,  diffuse,  or  be  felt 
more  in  the  occiput  (in  aneurysm  of  the  basilar  artery).  Vomit- 
ing, dizziness  and  stupor  (corresponding  to  the  reduction  of  brain 
space)  are  present,  while,  on  the  contrary,  choked  disc  is  infre- 
quent. A  pulsating  vessel  murmur,  heard  over  the  skull,  is  con- 
sidered an  especially  characteristic  symptom.  However,  this  is 
found  in  other  diseases,  and  also  in  normal  children.  The  develop- 
ment of  the  process  is  often  very  rapid.  The  localization  is  to  be 
inferred  from  the  local  symptoms. 

Parasites  of  the  Brain  (Cysticercus  Cerebri). — Headache^ 
with  dizziness,  is  a  frequent  symptom;  but  the  characteristic 
signs  are  localized  attacks  of  cramps,  due  to  the  location  of  the 
cysticercus  in  a  circumscribed  area  of  the  motor  region.  At- 
tacks of  an  epileptiform  character,  with  psychic  disturbances  (im- 
becility, confusion,  irritability),  are  present.  The  local  symp- 
toms differ  according  to  the  seat  of  the  parasite.  Frequently 
there  is  a  conspicuous  change  in  the  intensity  of  the  clinical 
symptoms.  A  cysticercus  tumor  may  be  diagnosed  if  the  possi- 
bility of  infection  has  existed  (association  with  infected  individ- 
uals, ingestion  of  raw  pork,  etc.),  or  if  the  cysticerci  are  found  in 
another  portion  of  the  body.  The  echinococcus  also  produces 
tumor  phenomena.  However,  it  is  very  seldom  that  one  can  suc- 
cessfully diag-nose  it,  since,  in  order  to  do  this,  an  echinococcus 
cyst  must  be  found  somewhere  else  in  the  body. 

Hydrocephalus  Internus. — Headache,  in  this  case,  is  usually 
constant.  For  the  rest,  the  disease  picture  is  similar  to  that  of 
meningitis  purulenta,  with  the  exceptions  that  the  fever  is  not  so 
high,  the  headache  is  less  severe,  and  frequently  a  perfect  cure 
occurs,  with  sequelae  of  eye  disturbances.  The  differentiation  is 
easiest  made   through   spinal   puncture.      Chronic   hydrocephalus 


188     PAIN  IN  DISEASES  OF  THE  NERVES,  BRAIN,  AND  CORD 

progresses,  in  most  instances,  under  the  symptom-complex  of  a 
brain  timior,  or  a  tumor  of  the  cerebellum.  According  to  Oppen- 
heim,  two  points  for  the  differential  diagnosis  are  to  be  taken 
into  consideration:  (1)  whether  there  exists  a  deficient  congenital 
development  (abnormal  size  and  form  of  the  skull)  ;  and  (2)  the 
occurrence  of  remissions  or  of  intermissions  of  a  month's  or  of  a 
year's  duration. 

Syphilis  of  the  Brain. — Anatomically  the  process  consists 
either  in  the  formation  of  tumor-like  gummata  or  in  changes  of 
the  vessel  walls,  especially  of  the  basilar  artery.  A  tubercular 
basilar,  gummatous  meningitis,  starting  in  the  region  of  the 
chiasm,  is  even  more  frequent.  Headache  is  one  of  the  earliest 
symptoms.  It  may  occur  months  or  years  before  other  signs. 
!Nightly  exacerbations,  recurring  at  a  certain  hour,  and  disappear- 
ing at  a  certain  time,  are  characteristic.  During  the  exacerbation 
the  patient  suffers  considerably  by  reason  of  the  severity  of  the 
pains.  In  the  intervals,  however,  the  pain  is  bearable.  It  is 
mostly  felt  as  a  diffuse  pain,  situated  deep  within  the  skull. 
Sometimes  it  has  a  circumscribed  border,  if  the  process  reaches 
the  convexity.  In  these  cases,  also,  a  circumscribed  percussion 
sensibility  may  be  present.  Other  constitutional  symptoms  be- 
long to  the  picture  of  cerebral  lues ;  for  instance,  vomiting,  dizzi- 
ness, attacks  of  unconsciousness,  psychic  disturbances,  dementia, 
stupor  and  states  of  irritability  occur  in  a  paroxysmal  manner, 
alternating  with  periods  of  normal  consciousness.  In  addition  to 
these,  there  is  paresis  or  paralysis  of  the  cranial  nerves,  especially 
the  optic,  and  oculomotor- j)tosis  is  especially  frequent.  Any  of  the 
other  cranial  nerves  may  be  involved  in  differing  combinations. 
The  repeated  change  in  the  intensity  and  the  final  complete  dis- 
appearance of  all  the  symptoms  are  typical.  The  onset  of  hemi- 
plegia, which  develops  in  the  course  of  one  or  two  days  without 
disturbances  of  consciousness,  is  a  frequent  symptom. 

Hysteria. — The  headache,  frequently  felt  as  a  dull  pressure 
in  the  entire  area  of  the  skull,  may  often  be  localized  to  a  cir- 
cumscribed place  on  the  vortex,  in  the  occiput,  or  in  the  temple. 
It  is,  as  a  rule,  associated  with  hyperesthesia  of  the  scalp,  so  that 


CENTRAL  NERVOUS  SYSTEM  189 

the  slightest  touch  or  the  least  disturbance  of  the  hair  causes  a 
pain  which  increases  on  pressure.  Bodily  and  mental  exertion 
and  emotion  may  also  produce  increased  irritation.  The  condition 
is  improved  by  diverting  occupations  and  during  quiet  and  dark- 
ness. It  may  last  for  hours,  days  or  months,  and  does  not  leave 
the  patient  even  during  sleep.  The  remaining  hysterical  symp- 
toms are  of  so  many  forms  that  they  cannot  briefly  be  given  here. 

Neurasthenia. — Here,  also,  the  intensity  of  the  headache  is 
not  very  great.  It  appears  mostly  as  pressure  and  constriction 
of  the  entire  head,  the  feeling  often  being  strongest  in  the  region 
of  the  forehead,  and  not  seldom  in  the  occiput.  The  patient  also 
complains  of  a  contraction,  as  though  the  head  were  bound  with 
an  iron  band.  The  headache  of  neurasthenia  is  also  produced  or 
increased  through  great  bodily  or  psychic  irritation,  or  by  emo- 
tions. 

Hemicranic  Headache  (Migraine) . — The  real  attack  of 
headache  is  often  preceded  by  symptoms  which  bear  a  certain  re- 
lationship to  it.  Some  patients,  previous  to  the  attack,  feel  lan- 
guid, exhausted,  and  are  without  appetite,  or,  on  the  contrary, 
manifest  great  hunger.  As  aura,  Moebius  designates  certain, 
paresthesias,  which  may  or  may  not  precede  the  attack,  namely, 
eye  symptoms,  flying  bodies,  glittering,  narrowing  of  the  field  of 
vision  (especially  hemianoptic),  and  glistening  scotomata;  these 
may  occur,  for  instance,  as  a  light  point  in  one  or  both  eyes,  which 
is  diffused  or  travels  across  the  field  of  vision  in  a  zigzag  line. 
Other  forms  of  the  aura  are  unilateral  paresthesia,  aphasia,  con- 
fusion, states  of  anxiety,  etc.  The  attack  itself  consists  in  head- 
ache of  the  severest  degree.  Generally  it  occurs  after  waking, 
with  slight  intensity,  and  gradually  increases  to  an  unbearable 
degree.  It  lasts  for  a  few  hours  to  a  few  days.  Frequently  it 
stops  during  sleep.  There  are  patients  in  whom  migraine  attacks 
are  of  slight  severity,  and  in  whom  light  and  severe  paroxysms 
interchange.  In  the  intervals,  which  may  last  for  weeks  and 
months,  the  patient  feels  perfectly  well.  The  pain  is  mostly 
one-sided,  but  is  also  double-sided,  usually  in  the  forehead  and 
eye  region.     Less  frequently  the  occipital  region  is  attacked.     As 


190    PAIN  IN  DISEASES  OF  THE  NERVES,  BRAIN,  AND  CORD 

a  rule,  the  paiu  is  located  by  the  patient  as  deep  iu  the  skull, 
and  is  of  a  boring  or  tearing  character.  The  patient  may  say  he 
feels  as  though  his  head  were  in  a  vise,  as  though  it  were  bursting 
asunder,  or  as  though  it  were  being  belabored  with  a  hammer. 
The  countenance  of  the  patient  during  the  attack  is,  in  most 
cases,  pale,  although  in  some  instances  the  face  and  conjunctiva 
are  reddened.  During  the  attack,  also,  the  patient  is  very  sensi- 
tive to  all  forms  of  stimuli.  Noises,  smells  and  lights  increase 
the  pain.  Nausea  and  vomiting  sometimes  are  accompanying 
symptoms,  and,  in  most  cases,  the  attack  concludes  with  them. 

DIAGNOSIS  OF  HEADACHE  IN  DISEASES  OF  THE  BRAIN  AND 

MENINGES 

The  character  of  the  headache  alone  rarely  permits  an  accu- 
rate diagnosis  to  be  made.  Yet  each  and  every  one  of  the  cranial 
lesions  enumerated  have  some  features  which  predominate 
more  or  less.  Thus,  in  cerebral  lues,  our  attention  is  drawn  to 
the  night  attacks.     This  is  rare  in  other  forms  of  brain  disorder. 

Intensity. — The  intensity  of  the  pain  varies  greatly  in  dif- 
ferent cases.  The  severest  degrees  of  headache  are  most  frequently 
observed  in  leptomeningitis,  then  in  brain-tumors,  in  abscess, 
brain-syphilis  and  hemicrania.  Tolerable,  though  still  severe, 
headache  is  found  in  pach^aneningitis  ha^morrhagica  interna,  in 
some  forms  of  headache  in  hysteria,  and  in  aneurysm  of  the  basilar 
artery.  Headache  due  to  neurasthenia  and  disturbances  in  the 
circulation  of  the  brain  is  naturally  not  very  severe.  In  the 
first-named  gi'oup  of  cases  (pachymeningitis  interna  hsemorrhag- 
ica)  paroxysmal  exacerbations  occur,  giving  rise  to  very  con- 
spicuous manifestations  of  pain.  The  patient  groans,  whines, 
and  either  shows  dull  apathy  or  jumps  out  of  bed,  runs  about 
and  presses  his  head.  Pain  of  this  severity,  however,  is  only 
temporary,  and  the  very  manner  of  its  occurrence,  as  well  as  the 
character  of  the  free  intervals,  is  important  for  the  diagnosis  in 
some  cases. 

It  has  been  noted  that  the  paroxysms  of  pain  in  cerebral  sypli- 
ilis  may  be   expected  with  great  probability   during  the  night. 


CENTRAL  NERVOUS  SYSTEM  191 

The  pain  appears  at  a  certain  hour  after  the  patient  has  gone  to 
bed,  usually  at  the  same  hour  every  night.  In  the  periods  be- 
tween the  paroxysms  the  headache  is  either  of  little  intensity  or 
disaj^pears  entirely. 

The  typical  form  of  hemicrania  is  also  characterized  by  its 
paroxysmal  occurrence.  After  an  aura  of  short  duration,  or 
perhaps  without  an  aura,  there  appears  the  most  severe  pain, 
compelling  the  patient  to  lie  down  and  keep  absolutely  quiet. 
Usually  sleep  puts  an  end  to  the  attack,  but  frequently  the  pain 
appears  in  the  morning  after  awaking.  In  this  point,  therefore, 
the  pain  differs  from  that  in  lues  cerebri.  Another  feature  may 
be  used  for  the  diagnosis  of  hemicrania,  namely,  that  the  pauses 
between  paroxysms,  w^hich  may  last  for  days,  weeks,  even  months, 
are  perfectly  free  of  pain.  During  these  periods  the  patient  feels 
absolutely  well. 

Paroxysmal  exacerbations  occur  in  other  affections;  for  in- 
stance, purulent  leptomeningitis,  abscess,  tumor,  etc.  These  exac- 
erbations, however,  appear  irregularly,  and  the  periods  between 
the  paroxysms  are  by  no  means  free  from  pain.  It  is  important 
to  know  that  in  cases  of  brain  abscess  the  paroxysmal  exacerba- 
tions of  the  headache  appear  usually  during  the  development  and 
growth  of  the  pus  foci;  and,  obviously,  for  this  reason  they  are 
frequently   connected   with    fever-elevations. 

BetW'Cen  the  varieties  of  headache  characterized  by  their  great 
intensity  and  the  headache  wdiich  is  described  by  the  patient  as 
hyperesthesia  of  the  head  (pressure  or  heaviness)  there  are 
scarcely  any  intermediate  forms.  The  latter  sort  of  headache  is 
seen  in  neurasthenia,  hysteria,  and  disturbances  of  circulation  in 
the  brain.  It  is  characterized  in  most  cases  by  its  continuous 
course;  although  variations  in  intensity  may  occur,  they  do  not 
show  any  feature  characteristic  of  the  condition.  In  most  cases 
direct  spontaneous  paroxysms  of  pain  do  not  occur,  neither  are 
there  any  periods  perfectly  free  from  pain;  yet  the  feeling  of 
pressure  in  the  head  does  not  leave  the  patient,  even  in  his  sleep. 

Moderate  degrees  of  headache  occur  in  pachymeningitis  in- 
terna, prior  to,  or  after  a  comatose  attack,  and  also  without  any 


192     PAIN  IN  DISEASES  OF  THE  NERVES,  BRAIN,  AND  CORD 

coma.  Here,  also,  there  are  intermissions  of  pain  of  varying 
duration,  which  cease  on  the  onset  of  another  bleeding.  The 
headache  in  aneurysm  and  the  paroxysms  of  headache  in  hysteria, 
which,  as  a  rule,  occur  in  the  parietal  region,  are  somewhat  simi- 
lar to  those  in  pachymeningitis,  so  far  as  their  intensity  is  con- 
cerned. 

Localization  of  Pain. — Localization  gives  but  few  clews  for 
diagnosis.  True,  there  are  diffuse  headaches,  unilateral  headaches, 
headaches  involving  only  the  frontal  region,  as  w^ell  as  those  of  the 
occipital  region.  Finally  a  headache  may  have* a  circumscribed 
area ;  but  there  is  scarcely  one  of  those  localizations  which  might 
be  looked  upon  as  characteristic  of  any  definite  affection.  Xot 
infrequently  one  finds  all  of  these  localizations  involved  in  one 
and  the  same  disorder.  This  may  be  the  case  in  a  brain  tumor, 
for  instance.  Nevertheless,  some  affections  predilect  a  certain 
region  of  the  cranium.  We  know,  for  instance,  that  in  migraine 
headache  occurs  most  frequently  unilaterally.  Moebius  states  that 
among  patients  of  his  from  whom  he  could  obtain  reliable  state- 
ments fifty-seven  had  almost  constantly  unilateral  headache, 
whereas  twenty-five  declared  that  they  had  felt  it  on  both  sides. 
Moebius  doubts  the  reliability  of  the  second  statement.  On  the 
other  hand,  there  are  diseases  in  which  unilateral  headache  is, 
comparatively  speaking,  seldom  present ;  for  instance,  in  leptomen- 
ingitis, neurasthenia  and  in  disturbance  of  the  cerebral  circulation. 
Frontal  headache  is  observed  in  neurasthenia  comparatively  fre- 
quently, and  the  unilateral  headache  in  migraine  is  often  most  in- 
tensely felt  in  or  behind  the  eye.  Pressure  in  the  parietal  region 
is  frequently  met  with  in  hysteria,  is  mostly  circumscribed  and 
is  accompanied  by  sensitiveness  on  pressure.  In  a  comparatively 
large  number  of  diseases  the  painful  area  is  sharply  circumscribed, 
a  fact  often  noted  in  pachymeningitis,  in  brain  abscess  and  in 
cerebral  syphilis.  This  circumscribed  pain  is  generally,  also, 
associated  with  a  circumscribed  sensitiveness  on  pressure  (the  so- 
called  sensitiveness  on  percussion). 

The  tension  of  the  pain  helps  less  frequently  than  its  localiza- 
tion in  making  a   diagnosis.      Certainly  even  here  the  greatest 


CENTRAL  NERVOUS  SYSTEM  193 

caution  is  necessary ;  for  cases  in  which  a  tumor  in  the  occipital 
region  causes  frontal  headache  are  by  no  means  rare;  and  it  also 
happens  that  a  tumor  of  the  left  side  may  give  rise  to  pain  felt 
in  the  right  half  of  the  cranium.  If,  however,  a  pain  is  con- 
stantly felt  in  one  place,  or,  when  generally  diffused,  it  originates 
from  one  place,  no  mistake  will  be  made  if  one  locates  the  cause 
of  the  disease,  be  it  a  tumor  or  an  abscess,  in  that  region.  Pain 
in  the  occiput  or  neck,  radiating  into  the  back,  justifies  one  in 
assuming  that  the  focus  lies  below  the  tentorium.  We  may  as- 
sume, with  great  probability,  that  a  lesion  exists  in  the  same 
area  in  which  pain  is  present,  if  we  have  to  deal  with  a  pain  con- 
stantly confined  to  one  side,  or  to  the  frontal  region.  Of  course 
one  should  strictly  avoid  depending  upon  pain,  alone,  in  forming 
conclusions.  To  form  a  diagnosis,  which  often  implies  a  great 
responsibility,  all  the  other  observations  and  examinations  (which 
will  be  discussed  later)  must  be  resorted  to. 

Character  of  the  Pain. — The  character  of  the  headache  tells 
us  very  little  concerning  its  cause.  Patients  describe  various 
kinds  of  headache  in  quite  different  ways,  most  frequently  as 
dull,  pressing,  drawing,  cutting,  lancinating,  constricting,  driving 
asunder,  roaring,  pulsating,  and  throbbing.  Since  every  form 
may  occur,  in  very  different  intensities,  there  result  an  exceed- 
ingly large  number  which  are  of  only  very  little  value  for  the 
diagnosis.  If  there  is  a  kind  of  headache  to  which  we  may 
ascribe  a  characteristic  feature,  it  is  the  pulsating  and  throbbing 
variety.  It  is  found  most  clearly  pronounced  in  an  aneurysm  of 
the  cerebral  vessels,  but  also  in  hyperemia,  and  sometimes  in 
cases  of  abscess. 

A  knowledge  of  those  external  influences  wdiich  may  cause 
an  exacerbation  of  an  already  existing  headache,  or  which  are 
capable  of  producing  headache,  is  more  important  for  the  diag- 
nosis than  are  the  location  and  the  character  of  the  pain.  It  has 
been  emphasized  that,  in  those  affections  in  which  the  sensitive 
area  is  circumscribed,  an  increase  of  the  headache  can  be  brought 
about  on  pressure,  with  the  finger,  or  by  striking  with  the  percus- 
sion hammer.    These  affections  are  pachymeningitis,  brain  abscess, 


194     PAIN  IN  DISEASES  OF  THE  NERVES,  BRAIN,  AND  CORD 

cerebral  syphilis  and  hysteria.  There  are  other  cases  in  which 
the  headache  gi'ows  considerably  worse  by  the  increase  of 
internal  brain  pressure,  such  as  occurs  in  coughing,  sneezing, 
pressing,  stooping.  This  is  the  case  in  brain  abscess,  brain 
tumor,  and  passive  congestion.  Sometimes  movement  of 
the  head  increases  the  headache,  especially  in  meningitis  and 
migraine. 

In  the  latter,  according  to  Moebius,  movements  of  the  eye 
have  a  much  more  unfavorable  effect  than  those  of  the  whole  head. 
The  upright  position  of  the  body  has  an  unfavorable  influence 
upon  anemic  headache,  whereas  horizontal  position  increases  an 
hyperemic  headache.  Headache  due  to  abscess,  tumor  and  hemi- 
crania  may  be  increased  by  alcoholism.  In  conclusion,  it  may  be 
added  that  mental  exertions  and  emotions  are  able  to  elicit  and 
to  increase  headache  in  neurasthenia,  hysteria  and  hemicrania, 
and  the  same  factors  may  aggi-avate  the  headache  in  case  of 
tumor. 

Influence  of  Therapy. — Diverting  occupation,  eating,  and 
rest  influence  headache  in  a  favorable  way,  especially  nervous  and 
hysterical  headache.  According  to  Moebius,  however,  they  may 
alleviate,  also,  less  severe  attacks  of  migraine.  This  latter  often 
may  be  cured  or  alleviated,  without  any  other  treatment,  by 
removal  of  irritants  (light,  noise,  etc.). 

By  the  observation  of  these  circumstances,  it  will  often  be 
possible  to  draw,  from  the  character  of  the  headache,  a  conclusion 
as  to  its  cause.  A  severe  pain,  for  instance,  which  apjjears 
paroxysmally  on  one  side,  and  which  is  favorably  influenced  by 
rest  and  ends  with  vomiting,  may  be  looked  upon  with  great  prob- 
ability as  hemicrania ;  nightly  exacerbations  point  to  cerebral  lues, 
whereas  headache  that  occupies  the  cortex  makes  us  think  first  of 
hysteria.  It  is  not  the  task  of  the  diagnostician,  however,  to 
make  the  diagnosis  from  one  single  symptom,  but  eventually  he 
will  utilize,  in  making  the  diagnosis,  all  the  signs  of  the  disease. 
In  the  following  lines,  therefore,  we  will  discuss  all  those  factors 
by  which  the  individual  affections  of  the  brain  and  spinal  cord 
may  be   differentiated;   and  for   the   sake  of  completeness  those 


CENTRAL  NERVOUS  SYSTEM  195 

affections  Avill  be  discussed  here  which  are  not   accompanied  hy 

jDain. 

DIFFEEEXTIAL    DIAGNOSIS 

Brain  Abscess. — If  tlie  analysis  of  the  pain  has  shown  that 
we  have  to  deal  with  a  brain  abscess,  the  following  conditions 
will  come  into  consideration  for  the  differential  diagnosis: 

Beaix  Tu:mok. — Against  this  would  speak  the  etiology  (with 
the  exception  of  traumatism,  which  also  may  cause  a  tumor), 
the  fever,  the  chills,  and  the  comparatively  more  rapid  course 
(weeks  to  months).  A  well-marked,  choked  disc  (optic  neuritis 
occurs  also  in  an  abscess),  as  well  as  the  better-marked  phenomena 
of  pressure,  in  general,  would  indicate  tumor. 

Leptomexixgitis  Purulexta. — This  takes  a  course  even 
more  rapid  than  abscess — days  and  weeks.  It  shows  high  fever 
and  acceleration  of  the  pulse  (in  case  of  abscess  only  low  grades 
are  observed),  hyperesthesia  of  the  organs  of  sense,  of  the  skin 
and  muscles,  involvement  of  the  cranial  nerves,  scaphoid  retrac- 
tion of  the  abdomen,  and  rigidity  of  the  muscles ;  whereas  optic 
neuritis,  retardation  of  the  pulse,  less  stupor  and  a  negative  result 
of  lumbar  puncture,  i.e.,  a  clear  puncture-fluid,  rather  speak  in 
favor  of  a  diagnosis  of  brain  abscess. 

Leptomexixgitis  Serosa. — This  occurs  either  as  a  primary 
affection,  or  as  an  accompanying  symptom  of  an  otitis  media. 
It  may  heal  spontaneously.  In  addition  to  this,  the  greater  fre- 
quency of  a  choked  disc  and  of  disturbances  of  sight  would  speak 
against  brain  abscess. 

Otitis  Media. — This  may  cause  diagnostic  difficulties  by  the 
occurrence  of  cerebral  symptoms,  but  can  be  recognized  by  the 
disappearance  of  the  latter  on  removal  of  the  pus. 

ExTE.yDURAL  Abscess  (In  Sequence  to  a  Suppuration  of  the 
Ear). — This  is  indicated  by  the  presence  of  focal  symp- 
toms and  the  absence  of  local  signs,  i.e.,  the  absence  of 
the  inflammatory  swelling  and  painfulness  in  the  region  of  the 
mastoid  process. 

Sinus  Thrombosis. — Here  are  found,  in  contradistinction  to 
brain  abscess,  pyemic  fever  and  acceleration  of  the  pulse,  com- 


196     PAIN  IN  DISEASES  OF  THE  NERVES,  BRAIN,  AND  CORD 

plete  absence  of  any  disturbance  of  consciousness,  more  frequent 
occurrence  of  choked  disc,  and  externally  a  thrombosis  of  the 
jugular  vein  in  the  neck.  On  the  other  hand,  focal  symptoms 
speak  for  the  presence  of  an  abscess. 

Hemorrhages  into  the  Meninges. — When  caused  by  trau- 
matism, they  proceed  without  any  fever,  and  follow  directly  after 
the  injury. 

Migraine. — Against  it  speak  both  etiology  and  absence  of 
fever. 

Traumatic  ISTeuroses,  Hysteria  and  Neurasthenia. — 
They  may  occur  as  concomitant  symptoms  of  a  brain  syndrome, 
or  may  be  independent  affections,  and  only  simulate  these. 

Brain  Syphilis. — This  is  mostly  accompanied  by  the  loss  of 
pupillary  reaction  to  light,  and  can  be  surely  diagnosed  by  the 
positive  result  of  Wassermann's  reaction  and  of  antiluetic  treat- 
ment. 

Leptomeningitis. — In  the  differential  diagnosis  of  leptomenin- 
gitis quite  a  number  of  diseases  come  into  consideration  in  which 
focal  symptoms  always  decide  in  favor  of  meningitis. 

Pneumonia^  Typhoid  Fever  and  Pyemia. — Rusty  sputum 
and  dullness  over  the  lungs  speak  for  pneumonia;  gradual  devel- 
opment and  the  positive  result  of  Gruber-Widal's  reaction  speak 
for  typhoid  fever ;  retardation  of  the  pulse,  stiff  neck  and  paraly- 
sis of  the  cranial  nerves,  as  well  as  the  intense  headache,  continu- 
ing also  during  the  coma,  speak  for  meningitis;  frequent  chills, 
skin  and  rectal  bleeding,  and  joint  swelling  speak  for  pyemic 
condition. 

Brain  hemorrhages^  embolus  and  thrombosis^  as  well  as 
encephalitis  ilemorrhagica  never  cause  fever-elevations  of 
such  a  duration  as  seen  in  meningitis. 

Otitis  media  is  confused  with  meningitis  principally  because 
the  ear  trouble  is  followed  by  a  serous  leptomeningitis.  As  such 
a  serous  meningitis  often  can  be  differentiated  from  a  purulent 
one  only  with  difficulty,  a  differential  diagnosis  can  be  made  in 
most  cases  only  by  the  disappearance  of  the  meningeal  symptoms 
after  the  evacuation  of  the  otitic  focus. 


CENTRAL  NERVOUS  SYSTEM  197 

In  uremia,  albumin  and  formed  elements,  as  a  rule,  are 
found  in  the  urine. 

The  SEROUS  form  of  meningitis  is,  as  above  mentioned,  diffi- 
cult to  differentiate  from  the  purulent  form.  In  most  cases  the 
fever  is  less. 

Delirium  Tremens, — Stiff  neck  and  the  extremely  severe 
headache  speak  against  it. 

Tuberculous  meningitis  occurs  in  early  childhood  (2  to  14 
years).  It  does  not  set  in  in  such  an  abrupt  manner,  and  shows 
frequent  remissions  (of  temperature,  stupor,  etc.). 

In  children  the  stomach  and  intestinal  disturbances  may 
cause  symptoms  similar  to  those  of  leptomeningitis,  and  may  give 
rise  to  confusion  in  diagnosis.  However,  the  influence  of  the  diet 
and  the  action  of  a  purgative  will  soon  clear  the  diagnosis. 

Brain  Tumor. — Hysteria  may  be  differentiated  by  its  head- 
ache, spasmodic  attacks  and  hemiplegic  paralysis.  Choked  disc 
and  focal  symptoms  will  guide  us  here,  but  it  must  not  be  for- 
gotten that  both  affections  may  occur  together.  The  possibility 
of  influencing  the  condition  psychically  speaks  for  hysteria.  In 
case  of  a  tumor  we  find  also,  during  the  acme  of  the  pain,  retarda- 
tion of  the  pulse  and  vomiting.  These  are  found  in  hysterical 
headache,  only  when  it  occurs  on  one  side. 

Concerning  migraine^  which  might  give  rise  to  confusion  by 
the  severity  of  the  headache  and  vomiting,  we  must  be  guided  by 
the  history  (heredity  in  migraine)  and  by  the  presence  of  choked 
disc  and  focal  symj)toms  in  tumor  of  the  brain. 

Paresis  often  comes  into  review  in  the  diagnosis  of  brain 
tumor.  The  clinical  symptoms  may  be  very  similar.  A  positive 
Wassermann,  a  positive  cell  count,  and  a  positive  globulin  reac- 
tion almost  certainly  speak  for  paresis  and  against  a  brain  tumor. 
In  paresis  choked  discs  are  not  frequent.  The  attacks  of  cortical 
epilepsy  occurring  in  both,  and  which  in  the  external  manifesta- 
tions are  similar,  usually  leave  little  permanent  palsy  in  paresis. 

Multiple  sclerosis  comes  into  consideration  in  affections  of 
the  cerebellum,  of  the  pons,  and  of  the  corpora  quadrigemina, 
which    likewise    produce    intention    tremors,    nystagmus,    spastic 


198     PAIN  IN  DISEASES  OF  THE  NERVES,  BRAIN,  AND  CORD 

ataxia,  as  well  as  paretic  s^inptoms  in  the  extremities.  To  these 
must  be  added  the  occurrence  of  atrophy  of  the  optic  nerve,  if 
they  are  accompanied  by  brain  symptoms.  However,  the  general 
symptoms  of  the  tumor,  such  as  severe,  continuous  headache,  the 
retardation  of  the  pulse,  vomiting  and  stupor,  do  not  belong  to  the 
clinical  picture  of  multiple  sclerosis.  In  epilepsy,  which  has  a 
certain  similarity  to  tumor  in  its  paroxysmal  character,  the  gen- 
eral symptoms  will  facilitate  the  differential  diagnosis. 

Pachymeningitis  Haemorrhagica  Interna. — Differential  diag- 
nostic points  speaking  against  pachymeningitis  are  either  the  en- 
tire absence  of  stiff  neck  or  the  presence  of  a  slightly  stiff  neck, 
as  well  as  the  rare  involvement  of  the  basal  cranial  nerves;  how- 
ever, both  signs  occur  also  in  pachymeningitis,  if  it  is  located  at 
the  base  of  the  brain. 

Cerebral  hemorrhage  frequently  is  with  difficulty  differen- 
tiated from  pachymeningitis.  The  absence  of  the  above-described 
symptoms  would  lead  to  a  consideration  of  a  hemorrhage  into  the 
brain  substance;  and  the  change  of  symptoms,  the  choked  disc 
and  the  intercurrent  appearance  of  convulsions  to  that  of  pachy- 
meningitis. 

In  EMBOLISM  and  thrombosis  elevation  of  temperature  is 
rare  in  the  later  stages,  and  phenomena  of  brain  pressure  are 
absent. 

Migraine  may  also  come  into  question  in  the  basal  form  of 
pachymeningitis.  Inherited  predisposition,  as  w^ell  as  a  rapid 
course  without  fever,  speaks  for  migraine. 

THALAMIC    PAINS    AND    THE    THALAMIC    FUNCTIONS' 

While  central  pains,  probably  due  to  lesions  in  and  about  the 
basal  ganglia,  were  first  suspected  by  N^othnagel,  it  is  chiefly  to 
the  studies  of  Dejerine  and  Roussy  that  we  are  indebted  for  the 
clearing  up  of  the  question  of  pains  due  to  lesions  of  this  region. 

Dejerine  and  his  students  have  shown  that  lesions  of  the 
thalamus,  especially  of  certain  of  its  nuclei,  proauce  a  character- 

'  Written  by  Dr.  Smith  Ely  Jelliffe,  New  York,  U.  S.  A. 


CENTRAL  NERVOUS  SYSTEM  199 

istic  picture,  the  thalamic  s^Tidrome  (Jelliffe).  in  which  severe 
and  persistent  pains  form  a  prominent  part. 

These  pains  usually  involve  the  side  of  the  body  on  which 
the  lesion  takes  place,  and  are  noted  for  their  severity,  their  per- 
sistency, and  their  resistance  to  analgesics. 

The  entire  picture  of  the  thalamic  syndrome  is  so  character- 
istic that  its  somewhat — at  first  sight — anomalous  symptoms 
should  be  given  in  detail.  This  is  all  the  more  important  since 
many  patients  with  the  thalamic  syndrome  are  thought  to  be  ma- 
lingerers or  hysterical. 

The  usual  thalamic  syndrome  begins,  as  a  rule,  with  a  mild 
apoplectiform  attack.  It  may  be  severe,  or  it  may  be  so  mild  as 
to  escape  ordinary  observation.  After  a  certain  length  of  time, 
the  motor  weakness  of  the  early  slight  or  severe  hemiplegia  disap- 
pears entirely,  or  to  a  greater  or  less  extent.  The  patient  has  some 
difficulty  in  managing  his  hand  and  leg,  and  it  appears  to  be  dif- 
ferent from  the  hand  of  the  well  side.  Then  pains  are  felt  on  the 
affected  side.  They  may  at  first  have  been  only  uncomfortable 
sensations  in  the  skin  of  the  side;  they  usually  take  the  form  of 
acute  shooting  pains,  and  may  be  in  the  entire  half  of  the  body,  or 
may  be  limited  to  the  face,  to  the  upper  extremity,  or  to  the  lower 
limbs.  They  rarely  cross  the  middle  line,  although  in  double 
thalamic  lesions  both  sides  of  the  body  show  painful  distributions. 

The  nerve  trunks  are  absolutely  painless;  they  are  not  swol- 
len, and  careful  search  for  Valleix's  or  Trousseau's  points  is 
unavailing.  There  is  nothing  to  point  to  a  neuralgic  or  a  neuritic 
process. 

These  pains  stab  and  jump  and  throb,  and  are  complained  of 
as  excruciating.  The  ordinary  analgesics  do  not  touch  them ;  even 
morphin  is  unavailing,  at  times,  in  checking  their  severity. 

^Notwithstanding  these  severe  pains,  it  may  be  that  careful 
sensory  examination  shows  that  the  patient  is  unable  to  distin- 
guish pain  at  all.  This  anomalous  condition  is  further  compli- 
cated by  the  fact  that  a  pin  prick  which  cannot  be  recognized  a? 
a  pin  prick,  the  patient  being  unable  to  tell  the  difference  between 
the  head  and  the  point  of  a  pin,  is  nevertheless  felt  as  a  disagree- 


200     PAIN  IN  DISEASES  OF  THE  NERVES,  BRAIN,  AND  CORD 

able  sensation.  Here,  then,  is  the  apparent  absurdity  of  a  patient 
who  cannot  tell  pain,  yet  has  a  disagreeable  sensation  when 
pinched,  still  suffering  excruciating  pain.  Not  only  may  the 
patient  be  unable  to  tell  a  pin  point  from  a  pin  head,  but  he 
cannot  recognize  the  difference  between  heat  and  cold,  and  burn- 
ing sensations,  recognized  on  the  sound  side,  are  translated  as  dis- 
comfort only  on  the  thalamic  side.  He  also  loses  superficial  sensi- 
bility. The  touch  of  cotton  wool  is  lost.  Furthermore,  these  pa- 
tients have  lost  their  deep  sensibility.  The  position  sense  is  gone, 
and  they  fail  to  recognize  objects  placed  in  the  hand.  The  rough- 
ness of  a  lump  of  sugar  may  be  interpreted  as  a  disagreeable  sen- 
sation, but  is  not  recognized  as  roughness. 

Moreover,  these  patients  sliow  slight  motor  incoordination 
in  the  hand  or  leg;  they  are  ataxic,  and  more  or  less  choreiform 
or  athetoid-like  movements  are  present  in  the  afflicted  side. 

In  some  patients  there  are  residual  signs  of  a  hemiplegia; 
slight  spasticity,  perhaps;  slight  clumsiness,  increased  radius- 
periosteal  reflexes,  triceps  reflexes ;  perhaps  lost  abdominal  reflexes 
on  that  same  side;  increased  patellar  reflex,  a  clonus  and  exag- 
gerated Achilles  jerks.  A  Babinski  extension  of  the  great  toe  is 
often  absent,  but  may  be  present.  Chaddoch,  Gordon  and  Oppen- 
heim's  signs  vary  considerably.  The  motor  synergistic  phe- 
nomena, described  by  Babinski,  Grasset,  and  Hoover,  are  all  apt 
to  be  present. 

One  feature  of  special  moment  found  in  thalamic  lesions  and 
which  has  been  emphasized  by  Head  and  Holmes  is  an  excessive 
response  to  affective  stimuli  and  the  change  in  behavior  in  states 
of  emotion  of  the  abnormal  half  of  the  body.  Thus,  in  many 
eases  of  pure  thalamic  lesion,  if  a  pin  be  lightly  dragged  across  the 
face  or  trunk,  from  the  sound  to  the  affected  side,  the  patient 
exhibits  intense  discomfort  when  it  passes  the  middle  line.  He 
not  only  complains  that  it  hurts  him  more,  but  the  face  may  be- 
come contorted.  JSTotwithstanding  this,  he  is  unable  to  tell 
the  difference  between  the  point  and  the  head  of  the  pin.  The 
same  type  of  over-response  is  found  to  other  forms  of  stimuli. 
Thus  deep  pressure,  which  cannot  be  measured  at  all,  also  ev^oket 


CENTRAL  NERVOUS  SYSTEM  201 

an  over-response ;  the  same  is  true  for  extremes  of  heat  and  cold, 
in  spite  of  the  fact  that  the  patient  is  imable  to  distinguish  be- 
tween them.  Visceral  sensibility,  scraping,  roughness,  vibration 
and  tickling  all  show  this  over-response  in  the  affected  side. 

Not  only  are  painful  stimuli  over-reacted  to,  but  pleasurable 
stimuli  occasion  a  like  over-response.  Furthermore,  in  states  of 
emotion,  there  may  be  different  manifestations  on  the  two  sides 
of  the  body,  just  as  painful  and  pleasurable  stimuli  may  produce 
a  stronger  reaction  on  the  affected  side.  Thus  some  patients  can- 
not hear  music  without  its  causing  sensations  in  the  affected  side, 
or  even  causing  motor  unrest,  movements  of  the  leg  with  shaking. 
The  choreiform  movements,  which  are  notable  motor  features, 
under  the  influence  of  emotional  stimuli  may  be  markedly  in- 
creased. 

From  this  it  can  readily  be  seen  that  the  thalamic  syndrome 
is  a  most  important  clinical  picture,  and  that  its  more  careful 
study  is  bound  to  throw  considerable  light  upon  the  whole  ques- 
tion, not  only  uj^on  the  subject  of  pain-perception,  but  also  upon 
emotional  attitudes  to  all  forms  of  stimuli.  In  fact,  it  opens  the 
way  to  the  most  important  of  all  of  the  questions  taken  up  in  this 
book.  Through  the  study  of  the  thalamus  the  entire  sensory  side 
of  the  human  organism  will  be  revealed,  and  it  may  readily  be 
seen  that  sensory  neurology  will  be  the  neurology  and  possibly 
the  psychiatry  of  the  next  decade. 

Thus  far  the  study  of  the  thalamus  has  shown  that  it  contains 
the  terminations  of  all  of  the  secondary  sensory  paths.  In  it 
sensory  impulses  of  every  kind  are  regrouped  and  again  redis- 
tributed. This  redistribution  takes  place  not  only  within  the 
thalamus  itself,  giving  us  thalamo-thalamic  paths,  but  it  also  goes 
to  the  cortex  in  a  fairly  large  series  of  thalamo-cortical  paths. 
The  thalamo-thalamic  j)aths  seem  to  pass  to  important  centers, 
constituting  what  Head  and  Holmes  have  termed  the  "essential 
organ"  of  the  thalamus  which  forms  the  main  center  for  certain 
fundamental  elements  of  sensation.  It  is  a  center  which  is  com- 
plementary in  function  to  the  sensory  cortex,  and  has  distinct 
though  related  functions.     The  lateral  part  of  the  thalamus  con- 


202     PAIN  IN  DISEASES  OF  THE  NERVES,  BRAIN,  AND  CORD 

tains  the  cortico-thalamic  paths  through  which  the  cortex  influ- 
ences the  essential  center,  controlling  and  checking  its  activity. 
Analogous,  in  a  way,  is  the  activity  of  the  motor  cortex  upon  the 
anterior  horn  nuclei  of  the  medulla  and  spinal  cord.  The  ex- 
cessive response  to  affective  stimuli,  pain  as  well  as  others,  is 
due  to  a  removal  of  this  cortical  control,  just  as  an  excessive 
motor  reflex  reaction  recurs  when  the  pyramidal  tract  does  not 
bring  down  cortical  stimuli  from  the  motor  area. 

The  activity  of  the  thalamic  center  is  of  special  import  in  our 
study  of  pain,  for  it  has  been  pointed  out  that  in  lateral  thalamic 
lesions  there  is  an  actual  overloading  of  sensation  with  feeling 
tone. 

The  pains  and  paresthesias,  found  in  many  thalamic  cases, 
have  been  thought  to  arise  from  "irritative"  lesions,  but  this  is 
probably  not  so.  It  would  seem  that  the  thalamic  center  is  a  true 
center  for  perception  of  sensations,  including  pain,  and  that  the 
cortex  has  a  definite  relationship  to  these,  so  that  it  may  modify 
the  affective  response  and  naturally,  thereby,  the  motor  responses. 
The  essential  thalamic  organ  is  a  center  for  conscious  perception 
for  certain  elements  of  sensation.  It  responds  to  those  stimuli 
which  are  capable  of  evoking  pleasure  and  discomfort  or  con- 
sciousness of  a  change  in  state.  The  feeling  tone  of  the  body, 
which  has  often  been  termed  the  somatic  or  visceral  tone  sensa- 
tion,  is  a   thalamic   function. 

What  the  interrelations  between  the  thalamus  and  the  cortex 
are,  so  far  as  sensation  is  concerned,  need  not  detain  us  at  this 
point.  We  have  chosen  to  isolate,  for  the  purposes  of  our  treatise, 
that  sensation  known  as  pain,  therefore  a  discussion  of  the  whole 
question  would  be  somewhat  out  of  place.  Yet,  a  word  should 
be  added  as  to  the  cortical  function  in  sensation. 

The  sensory  cortex  permits  a  concentration  of  attention  on 
any  part  of  the  body  which  is  stimulated.  Such  stimuli  are 
passing  through  sensory  paths  to  the  thalamus.  Many  of  low 
threshold  value  pass  to  the  cortex  or  are  automatically  taken  care 
of  by  the  thalamus.  Those  of  high  threshold  value  pass  into 
the  essential  organ  of  the  thalamus  and  into  consciousness,  where 


CENTRAL  NERVOUS  SYSTEM  203 

they  bring  about  a  tendency  to  excessive  reactivity,  just  as  the 
anterior  horn  cells  of  the  cord  react  excessively  if  uncontrollo  1. 
The  sensory  cortex  gives  a  quick  reacting  mechanism  to  dampen 
down  the  affective  response  to  thalamic  over-activity. 

This  leads  us  to  an  interesting  deduction  made  by  Head  and 
Holmes,  in  the  study  herein  freely  made  use  of,  that  the  aim  of 
human  evolution  is  the  domination  of  feeling  and  instinct  by 
discriminative  mental  activities.  This  struggle  on  the  highest 
plane  of  mental  life  is  begun  at  the  lowest  afferent  level,  and  the 
issues  become  more  sharply  outlined  the  nearer  sensory  impulses 
approach  the  field  of  consciousness. 

In  the  accompanying  table  an  attempt  is  made  to  simplify  the 
diagnosis  between  a  cerebral  (sensory)  cortex  lesion  and  one  of 
the  thalamus.  The  defining  factors  are  obtained  principally  from 
the  work  of  Head. 


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g 

o 
O 

Sensation    present,  but    the    response    of    the 
patient  to  the  same  stimulus  shows  a  want  of 
uniformity  and  irregularity  of  response,  so  that 
at  one  time  he  may  respond  to  a  pressure  of 
100  gm.  and  at  another  21  gm.  may  produce 
on  the  same  spot  a  response. 

Tendency  to  persistence  of  sensation  so  that  an 
interrupted  stimulus  may  seem  to  be  con- 
tinuous. Hallucinations  of  touch,  owing  to  the 
persistency  of  stimulus  sensation,  may  occur. 

Fatigue  quickly  results  in  the  part  supjjlied  by 
the  affected  area.      That  is,  the  part  may  re- 
spond to  pressure  of  30  gm.,  but  will  not   to 
100  gm.     Sensibility  to  touch  by  cotton  wool 
is  never  lost  over  hair-dad  parts. 

No  change  in  the  threshold  to  measurable  pain- 
ful or  uncomfortable  stimuh.     No  increase  or 
decrease  of  response  to  painful  stimulus. 

iz; 
c 
a 

o 

M 

May  be  lost  on  affected  half  of  body.     In  all 
cases  the  objective  pain,  when  present,  is  defi- 
nite and  the  threshold  of    response  is  con- 
stant. 

Objective  pain  lost  in  half  of  body. 

Subjective  pains  are  present  in  the  same  side  of 
the  body  as  the  lesion.     They  are  persistent, 
paroxysmal,  often  are  intolerable  and  yield  to 
no  therapeutic  measures.     There  is  a  tendency 
to  react  excessively  to  unpleasant  stimuh,  such 
as  the  prick  of  a  pin,  painful  pressure,  excessive 
heat  or  cold ;  on  the  affected  side  these  produce 
more  pain  than  on  the  normal  side.     Though 
in  some  cases  the  threshold  of  response  may 
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206 


CHAPTER  IX 

DISEASES   OF  THE  SPINAL  COED 

Diseases  within  and  about  the  spinal  cord  produce  principally 
two  different  kinds  of  pain,  namely,  back  pains  and  radiating 
pains.  The  former  are  more  or  less  continuous,  extending 
either  along  the  entire  vertebra,  or  occurring  in  certain  regions. 
The  latter  occur  in  the  extremities  and  in  the  nerve  trunk  along 
the  peripheral  portions  of  the  sensory  nerves.  It  would  be  of 
great  value  in  the  diagnosis  of  spinal  cord  diseases  if  the  pains 
were  at  all  definitely  characteristic.  Unfortunately,  this  is  not 
the  case.  Moreover,  there  are  a  number  of  diseases  of  the  spinal 
cord  in  which  pain  is  usually  absent.  Here  may  be  mentioned 
acute  poliomyelitis,  amyotrophic  lateral  sclerosis,  progressive  mus- 
cular atrophies  of  the  nuclear  type,  multiple  sclerosis,  and  various 
defect  anomalies.  On  the  other  hand,  affections  of  the  cord  or  of 
the  meninges,  especially  in  the  initial  stages,  are  apt  to  result  in 
pain.  Pains  localized  in  the  back  are  also  found  in  diseases  of 
other  organs,  and  there  are  also  in  the  back  radiating  pains  which 
are  not  characteristic  of  diseases  of  the  cord  or  its  membranes. 

It  will  also  be  important  to  consider  here  those  visceral  dis- 
eases, chiefly  of  the  musculature  of  the  back,  whose  pains  must  be 
differentiated  from  those  originating  in  the  cord  or  its  immediate 
coverings.  !Kot  until  disease  of  other  organs,  which  may  give 
rise  to  back  and  radiating  pains,  is  excluded,  can  the  pain  be  uti- 
lized for  the  diagnosis  of  disease  of  the  spinal  cord.  One  must, 
above  all,  be  able  to  recognize  neck,  back  and  pelvic  pains,  the 
causes  for  which  are  outside  of  the  central  nervous  system. 

There  is  an  entire  class  of  organs,  internal  and  external,  which 

207 


208  DISEASES    OF   THE    SPINAL    CORD 

can  cause  such  pains.  This  class  chiefly  composes  almost  all  the 
internal  organs  of  the  thorax  or  of  the  abdominal  cavity.  For  a 
consideration  of  the  back  pains  due  to  visceral  diseases,  see  page 
300. 

It  will  be  necessary,  in  every  case  of  back  pain,  to  exclude 
the  entire  class  of  visceral  comj^laints  before  one  sets  to  work  to 
indicate  the  pain  as  originating  from  the  spinal  cord  or  its  men- 
inges. Above  all,  in  doubtful  cases  a  systematic  examination  of 
the  internal  viscera  must  be  undertaken.  If  these  are  found  un- 
changed, we  must  refer  the  pain  to  disease  of  the  spinal  cord  or 
its  membranes.  If,  however,  in  connection  with  back  pain  one 
of  the  internal  organs  is  found  to  be  diseased,  the  object  of  the 
examination  will  then  be  to  ascertain  whether  the  pains  are  con- 
nected with  these  organs  or  with  the  central  nervous  system. 

CORD    CONDITIONS   WHICH    CAUSE    PAIN  ^ 

In  certain  cord  conditions  pain  is  an  important  factor.  We 
will  discuss  some  of  these  seriatim : 

Luxation  and  Fracture  of  the  Vertebra. — Luxation  and  frac- 
ture of  the  vertebra  produce  severe  radiating  pains  in  the  arm, 
trunk  or  leg,  according  to  the  site  of  the  injury.  If  it  lies  in  the 
cervical  vertebra,  it  may,  through  compression  of  the  occipital 
nerves,  cause  pain  in  their  area  of  distribution.  If  it  lies  in  the 
thoracic  vertebra,  it  will  cause  pain  by  pressure  upon  the  inter- 
costal nerves.  The  remaining  symptoms  depend  upon  the  situation 
and  remote  effect  of  the  lesion.  In  addition  to  the  sensory  signs 
there  is  paralysis  below  the  site  of  the  injury.  The  loss  of  sen- 
sation begins  usually  at  about  the  same  level,  though,  as  a  rule, 
somewhat  lower  than  the  lesion. 

'No  attempt  will  be  made  in  this  chapter  to  present  a  complete 
summary  of  the  clinical  pictures  of  the  various  forms  of  spinal 
luxation  or  fracture.  Such  must  be  sought  in  special  works  upon 
the  subject.  We  can  give  only  a  brief  summary  of  the  symptoms, 
laying  stress  upon  the  sensory  side  of  the  picture : 

1  Written  by  Dr.  Alfred  Neuman,  Vienna. 


CORD    CONDITIONS    WHICH    CAUSE   PAIN  209 

The  most  classical  pictures  are  produced  by  cervical,  dorsal, 
lumbosacral  and  cauda  equina  lesions. 

The  most  frequent  cause  for  the  first  type  is  direct  injury, 
diving,  falls,  falling  of  heavy  weights.  Either  dislocation  or  frac- 
ture may  occur.  One  finds  forward  displacement  of  the  head, 
there  are  usually  myosis  of  the  pupils,  greatest  on  the  side  most 
injured,  narrowing  of  the  palpebral  fissure,  retraction  of  the  eye- 
balls— which  eye  signs  are  due  to  involvement  of  sympathetic  cen- 
ters in  the  first  dorsal  region  of  the  cord  (Dejerine,  Klumpke). 
There  may  be  no  pain,  but  there  are  usually  anesthesia  and  anal- 
gesia below  the  level  of  the  lesion.  The  muscles  affected  indicate 
the  level  of  the  lesion  in  the  cord. 

Movement  of  the  head  or  neck,  however,  is  apt  to  create  sharp 
radiating  pains  at  about  the  level  of  the  injury.  Local  pain  on 
pressure  is  present. 

Dorsal  injuries  cause  similar  pictures  lower  down.  They  are 
usually  very  severe. 

Lumbosacral  and  caudal  lesions  affect  the  movements  of  the 
legs  and  the  functions  of  the  bladder,  rectum,  and  sexual  organs. 
Lesions  here  are  apt  to  result  in  much  pain,  especially  in  injury 
to  the  cauda  equina.  In  isolated  cord  lesions,  pain  is  apt  to  be 
missing,  but  in  caudal  involvement,  especially  later  in  the  disease, 
pain  is  frequent  and  very  often  severe. 

A  study  of  the  anesthesise  and  the  muscles  involved  is  neces- 
sary to  locate  the  precise  site  of  the  injury. 

Meningeal  Apoplexy. — Likewise  in  spinal  cord  hemorrhage, 
as  the  result  of  a  trauma,  pains  occur.  They  may  be  very  severe ; 
are  localized  in  the  back,  and  are  limited  either  to  a  part  of  the 
same  (pelvis,  interscapular  region,  or  the  neck),  or  spread  over  the 
entire  vertebral  column.  Pressure  on  the  vertebra  causes  a  slighter 
increase  of  pain  than  does  motion ;  consequently,  the  vertebral  col- 
umn is  held  in  a  stiff  position.  In  like  manner  radiating  pains 
occur  in  the  upper  or  lower  extremities,  according  to  the  location 
of  the  lesion.  The  remaining  symptoms  of  the  disease  present 
themselves  in  cramps,  tremors,  and  contractures  in  the  arms  and 
legs. 


210  DISEASES    OE   THE   SPINAL   CORD 

Hematomyelia. — Sudden  hemorrhage,  occurring  within  the 
spinal  cord,  in  the  majority  of  cases  causes  pain.  Some  hemato- 
myelias  run  a  painless  course.  The  location  of  the  pain  corre- 
sponds to  the  level  of  the  affected  area,  and  appears  either  as  back, 
shoulder,  pelvic  or  leg  pain.  Stiffness  of  the  vertebra  and  pressure 
sensibility  of  the  same  are  present  in  involvement  of  the  meninges. 
The  patient  presents  a  sudden  interruption  in  the  conduction 
paths.  The  remaining  symptoms,  produced  through  the  position 
and  the  spreading  out  of  the  area,  are  disturbances  of  sensibility, 
bladder  and  rectal  paralysis,  atrophies,  participation  of  the  arm, 
or  half-sided  paralyses,  etc. 

Caries  of  the  Vertebral  Canal. — In  this  disease  pain  plays  an 
important  part.  It  appears  very  often  as  local  pain,  increased  on 
motion,  and  limited  to  the  diseased  vertebra.  The  result  is  that 
the  patient  guards  against  exercise  involving  the  diseased  part, 
and  holds  it  in  a  stiff  position.  He  also  avoids  displacement  of 
the  diseased  vertebra.  With  the  local  pain,  radiating  pain  ap- 
pears, earlier  or  later,  and  has  different  localizations,  according  to 
the  vertebrae  involved.  In  disease  of  the  highest  cervical  vertebra 
the  pain  radiates,  through  the  occipital  nerves,  to  the  head  (neu- 
ralgia). If  the  cervical  cord  enlargement  is  damaged  by  bone  dis- 
ease, the  pain  radiates  into  the  arms.  In  compression  of  the  dorsal 
cord  girdle  or  intercostal  pain  occurs ;  and,  finally,  there  is  lan- 
cinating pain  in  the  limbs  in  affections  of  the  lower  enlargement 
of  the  cord.  The  pressure  sensibility  of  the  spinous  processes  of 
the  diseased  vertebrai  is  especially  characteristic.  It  is  very  pro- 
nounced, and  is  proportional  to  the  amount  of  pressure  used. 
On  the  contrary,  in  neurasthenia  and  in  hysteria  (diseases  in 
which  pressure  sensibility  of  the  vertebral  column  is  observed), 
there  is  greater  sensitiveness  to  a  light  touch  of  the  skin,  on  the 
elevation  of  a  fold,  than  to  a  strong  pressure.  In  hysteria,  pres- 
sure pain  is  often  greater  lateral  to  the  spinal  process  than  it  is 
over  it,  and  is  influenced  by  suggestion.  As  characteristic  of 
caries,  the  readiness  with  which  the  skin  lying  over  the  diseased 
vertebrae  responds  to  pain,  to  electrical  and  thermal  irritation  is 
especially  pronounced.     The  other  most  important  symptoms  are 


CORD    CONDITIONS   WHICH   CAUSE  PAIN  2U 

the  acute  kyphosis,  through  collapse  of  the  diseased  vertebrse,  the 
descending  abscess  (on  the  posterior  pharyngeal  wall,  along  the 
psoas  muscle,  or  into  the  inguinal  fossa  or  on  the  back),  and  the 
symptoms  referred  to  the  spinal  cord  or  the  spinal  roots. 

Tumors  of  the  Spinal  Cord  and  Vertebrae. — For  the  diagnosis 
of  these  conditions,  local  painfulness  of  the  vertebral  column 
and  radiating  pain  must  be  differentiated.  The  former  corre- 
sponds to  the  location  of  the  tumor,  and  is  increased,  especially 
upon  bending  forward  and  en  shaking  the  head.  This  symptom, 
however,  is  not  always  present.  It  is  possible  that  an 
inequality  exists  between  the  strong,  spontaneous  pain  and 
the  lighter  pressure  sensibility.  According  to  Petren,  only  a 
diffuse  painfulness  of  the  vertebral  column  can  be  a  symptom  of 
cord  tumor. 

More  frequent  and  more  clearly  pronounced  are  the  neuralgic 
pains  which  arise  from  pressure  on  the  posterior  roots.  As^  a  rule, 
they  are  described  as  intermittent  or  remittent,  and  may  be 
present,  according  to  the  location  of  the  tumor,  in  different  parts 
of  the  body.  If  the  tumor  is  present  at  the  cervical  enlargement, 
it  causes  radiating  pains  in  the  areas  corresponding  to  the  thoracic 
vertebral  column,  girdle  pains  around  the  thorax,  and  shooting 
pains  in  the  region  of  the  stomach  or  bladder.  When  the  tumor  is 
located  still  lower,  sciatic  pains,  on  one  or  both  sides,  are  often 
the  first  symptoms  of  the  not  yet  apparent  disease. 

In  addition  to  tumors  involving  the  cord  itself,  as  causes  of 
pain,  one  should  also  bear  in  mind  those  affections  of  the  vertebrae 
which  either  themselves  encroach  upon  the  cord,  or  which  produce 
such  changes  in  the  bones  that  they  make  pressure  upon,  or  cause 
involvement  of  the  cord.  The  most  important  of  the  bony  dis- 
orders of  the  vertebrae  is  tuberculosis.  Here  there  is  found 
localized  tenderness  over  the  spinal  vertebrae,  usually  sharply  lim- 
ited to  one  or  two  segments.  The  general  meningeal  pain  develops 
later,  whereas  the  more  severe  pressure  pain  originating  from  the 
pressure  on  the  roots  accompanies  the  settling  of  the  vertebrae,  i.  e., 
more  or  less  synchronous  with  the  kyphosis.  In  caries,  also,  there 
is  no  Wassermann,  in  the  fluid  the  number  of  cells  is  rarely  high, 


212  DISEASES    OF   THE    SPINAL    CORD 

the  globulin  content  nil.  (See  Caries  of  the  Vertebral  Column 
above. ) 

Gummatous  masses  act  like  tumors  at  times,  and  cannot  be  dif- 
ferentiated clinically. 

Acute  Spinal  Meningitis. — If  a  spinal  meningitis  is  added  to 
a  cerebral  meningitis  the  symptoms  of  the  spinal  trouble  are  the 
more  prominent.  Intense  pain  is  frequently  observed.  There  is 
also  a  local  painfulness  of  the  spinal  column,  especially  pro- 
nounced in  the  lumbar  region.  The  pains  are  increased  by  pres- 
sure and  shaking  (coughing,  sneezing),  but  especially  by  active 
and  passive  motion.  In  the  same  manner  the  simultaneously  oc- 
curring pains  radiating  into  the  arms  and  legs  are  increased.  For 
this  reason  the  patient  holds  the  vertebral  column  in  a  rigid  posi- 
tion. 

Pachymeningitis  Spinalis  Hypertrophica. — In  this  disease  we 
find  pains  in  the  neck,  in  the  occipital  region  between  the  shoul- 
ders, and  along  the  spinal  column ;  the  point  of  localization  de- 
pending upon  the  location  of  the  diseased  areas.  In  addition  to 
the  local  symptoms  radiating  pains  in  the  extremities  and  in  the 
trunk  occur.  In  the  cervical  variety  the  neuralgic  pains  corre- 
spond to  the  course  of  the  ulnar  and  median  nerves. 

Myelitis. — Pain,  which  is  not  the  most  important  symptom  in 
this  disease,  is  found  especially  in  the  beginning  stage,  or  as  a  pro- 
drome. In  the  chronic  stages  pain  is  not  a  constant  sign.  Back 
pains,  varying  according  to  the  location  of  the  diseased  areas, 
girdle  pains,  corresponding  to  the  upper  boundary  of  the  disturb- 
ances of  sensibility,  or  lancinating  pains  in  the  extremity,  gener- 
ally not  of  great  intensity,  are  present.  Pressure  sensibility,  as 
well  as  percussion  sensibility,  is  almost  never  found. 

Poliomyelitis  of  Children.  — In  the  prodromal  stages  of  the 
disease  pains  are  present  in  addition  to  fever,  convulsions  and 
vomiting.  These  pains  are  apt  to  be  very  diffuse,  but  are  especially 
severe  about  the  neck  and  occiput,  often  being  more  suggestive  of 
a  cerebrosj^inal  meningitis  than  a  poliomyelitis.  Diffuse  pains  of 
the  extremities  and  marked  hyperesthesia,  resembling  these  signs 
in  influenza,  are    extremely    frequent,    especially  in    some    epi- 


CORD    CONDITIONS    WHICH    CAUSE   PAIN  213 

demies.  A  poliomyelitis  may  run  a  course  indistinguishable  from 
a  polyneuritis,  save  that  in  the  latter  bony  sensibility  is  apt  to  be 
involved.  It  is  rarely  implicated  in  poliomyelitis.  Associated 
with  poliomyelitis  is  paralysis,  which  generally  occurs  suddenly 
in  the  course  of  the  night,  in  from  two  to  seven  days,  and  affects 
either  one  or  more  extremities,  generally  one  or  both  limbs.  The 
paralysis  is  flaccid,  and  the  skin  and  tendon  reflexes  are  absent. 
After  a  short  time  atrojjhy  of  the  muscle  and  reaction  of  d-egen- 
eration  are  demonstrable.  Then  the  affected  limbs  feel  cold  and 
are  livid  in  color.  Atrophy  and  secondary  contractures  ensue  in 
many  cases. 

Syphilis  of  the  meninges  and  of  the  cord  causes  pains  in  dif- 
ferent parts  of  the  vertebral  column,  which  are  increased  through 
movement  and  pressure,  are  of  great  severity,  with  nightly  exacer- 
bations, and  are  combined  with  radiating  pains  in  the  extremities 
and  the  trunk  (girdle  pain).  Through  compression  of  the  ante- 
rior roots  there  also  occur  atrophic  paralyses  of  the  extremities 
and  of  the  abdominal  muscles.  The  particij)ation  of  the  spinal 
cord  can  be  seen  through  an  interruption  (very  incomplete) 
of  the  conduction.  Spastic  paralysis  of  one  or  both  extremities 
is  also  of  frequent  occurrence.  Babinski's  and  Oppenheim's  signs 
are  then  present,  as  well  as  disturbances  of  sensibility  in  the  rec- 
tum and  bladder.  The  frequent  change  of  the  disease  picture  is 
characteristic.  Paralysis  maybe  present  one  day  and  then  disap- 
pear, and  it  may  frequently  be  observed  that  paralysis  and  per- 
fect motion  follow  one  another  in  the  same  region. 

Multiple  Sclerosis. — The  pains  are  similar  to  those  found  in 
tabes,  but  are  much  less  frequent.  Some  pain  is  observed  along 
the  spinal  column.  The  remaining  symptoms  are  familiar, 
namely,  spastic  paretic  symptoms  in  the  extremities,  intention 
tremor,  scanning  speech,  nystagmus,  passing  disturbances  of  sight, 
with  paleness  of  the  jDapilla,  headache,  dizziness,  and  mental  signs. 
In  the  later  stages,  marked  by  intense  contractiires,  pain  is  often 
very  intense.  It  is  due  to  the  contractures  and  may  also  appear 
early  in  the  disease  as  short  stabs,  occurring  at  the  time  of  a  con- 
tracture cramp  of  the  extremities,  principally  the  lower. 


2M  DISEASES    OF   THE    SPINAL   CORD 

Syringomyelia. — The  pains  which  are  most  often  observed  in 
this  disease  are  similar  in  character  to  the  lancinating  pains  of 
tabes  dorsalis.  They  are  often  very  severe,  and  radiate  into  the 
limbs  (sometimes  into  all  four)  and  around  the  trunk.  The  other 
symptoms  concern  the  development  of  atrophic  paralysis,  princi- 
pally, at  first,  in  the  upper  extremities,  beginning  in  the  small 
muscles  of  the  hand.  The  sensory  syndrome  consists  in  a  retention 
of  epicritic  touch  sensibility,  but  a  loss  of  pain  and  temperature 
sensibility.  Vasomotor  and  trophic  dis'turbances  are  frequent 
from  involvement  of  protopathic  conduction  fibers. 

Tabes  Dorsalis. — The  pains  in  tabes  dorsalis  are  localized 
sometimes  on  the  surface  of  the  body,  sometimes  in  the  hollow  vis- 
ceral organs.  The  former  appear  as  lancinating  pains  in  the  ex- 
tremities, or  as  girdle  pains  around  the  trunk.  These  pains  form 
one  of  the  first  symptoms,  and  often  appear  many  years  previous 
to  other  symptoms  of  the  disease.  They  come  on  abruptly,  while 
the  patient  is  in  the  best  of  health,  and  soon  reach  a  great  in- 
tensity. They  are  situated,  as  a  rule,  less  frequently  in  the  upper 
than  in  the  lower  extremities.  In  the  former  case,  they  are 
usually  not  so  severe.  In  the  legs  they  may  reach  their  greatest 
intensity.  The  pain  suffered  by  different  patients,  however,  varies 
in  intensity.  It  is  seldom  felt  in  the  skin,  but,  instead,  usually 
deep  in  the  muscles  or  in  the  bones.  The  attack  itself  may  last 
for  a  few  seconds  at  first,  then,  later  in  the  disease,  a  few  minutes, 
then,  in  the  final  stages,  may  persist  for  hours.  The  incidence  of 
the  attacks  seems  to  at  least  partly  depend  upon  outside  factors, 
as  weather,  worry,  wine,  and  women.  The  girdle  sensations  indi- 
cate only  different  localizations  of  the  lesion.  They  appear  as 
pressure,  tightness  on  the  breast,  as  though  the  patient  were 
bound  by  an  iron  band,  or  as  pressure  sensation  of  the  stomach 
or  bladder.  Pains  in  the  maxilla,  teeth,  or  ear  may  occur  in 
tabes,  in  fact,  in  the  distribution  area  of  any  sensory  nerve.  The 
pains  which  arise  in  tabes  in  the  internal  organs  (stomach,  blad- 
der, intestines)  occur  paroxysmally,  and  are  often  of  extreme 
severity,  when  they  are  termed  tabetic  crises.  Such  crises  are  not 
infrequently  very  early.     The  best  known  are  the  stomach  crises. 


CORD    CONDITIONS    WHICH    CAUSE    PAIN  215 

A  patient  in  perfect  health  suddenly  has  excruciating  pains  in  the 
stomach,  usually  accompanied  by  uncontrollable  vomiting.  Ra- 
diations into  the  shoulders  occur.  Some  patients  scream,  sigh,  and 
toss  in  bed,  while  others  remain  perfectly  quiet.  This  condition 
lasts  a  few  hours,  or  days,  rarely  longer.  Then  the  picture 
changes.  The  pains  and  vomiting  disappear,  and  the  patient  is 
able  to  eat  everything  without  distress,  the  same  as  though  he  were 
in  perfect  health.  These  intervals  of  freedom  last  for  different 
periods,  sometimes  months  or  years.  Then  other  crises  occur.  In 
the  intestines  the  crises  arise  as  colicky  pains  associated  with 
diarrhea ;  kidney  crises,  with  pains  similar  to  those  of  renal  colic, 
also  occur;  bladder  crises,  ureter  crises,  and  clitoris  crises,  corre- 
sponding to  pains  in  these  organs ;  eye  crises,  sudden  pains  arising 
in  the  eyes,  joined  with  redness,  lancination  and  contraction  of  the 
lids ;  laryngeal  crises,  sneezing  crises,  etc.,  also  occur. 

The  associated  symptoms  are  so  numerous  that  only  the 
most  important  can  be  mentioned,  namely : 

(1)  Disturbances  of  sensibility,  and,  in  addition  to  the  pain, 
paresthesias,  especially  in  the  extremities,  paralysis  of  sensibility 
of  the  skin,  of  the  muscles,  and  of  the  joints, 

(2)  Disturbances  of  the  reflexes  with  absence  of  the  patellar 
reflex  or  of  the  tendon  achilles  reflex,  the  tendon  reflexes  of  the 
upper  extremities,  and  of  the  pupil  reflexes   (Argyll-Robertson). 

(3)  Ataxia  of  the  extremities,  sho\\Ti  by  the  finger-nose  test, 
finger-finger  test,  knee-heel  test  and  by  Romberg's  test. 

(4)  Bladder  and  rectum  disturbances,  especially  inconti- 
nence, 

(5)  Trophic  disturbances  leading  to  spontaneous  fracture, 
atrophies  of  the  joints,  arthropathies,  falling  out  of  the  teeth,  and 
perforating  ulcer. 

(6)  Eye  symptoms,  which  are  often  temporary,  ptosis,  oph- 
thalmoplegies,  optic  nerve  atrophy. 

Neurasthenia. — Pain  in  the  back  of  the  head  is  a  frequent 
complaint  of  many  neurasthenics.  It  is  localized  to  a  circum- 
scribed part  of  the  vertebral  column,  or  spreads  out  over  the 
entire  circumference.     One  finds  pressure  sensibility  in  a  lesser 


216  DISEASES    OF    THE    SPINAL    CORD 

or  greater  part  of  the  spinal  column  corresponding  to  the  loca- 
tion of  these  pains.  It  is  characteristic  that  strong  pressure  is 
often  felt  to  be  less  painful  than  light  pressure.  The  pains  are  not 
as  severe  as  they  are  described,  as  may  be  seen  by  the  ease  with 
which  the  patient's  attention  is  distracted  from  the  pain.  Radiat- 
ing pains  in  the  trunk  and  in  the  extremities  are  also  frequently 
described.  In  regard  to  the  other  symptoms  of  neurasthenia,  they 
are  so  numerous  that  the  mere  enumeration  would  be  too  exten- 
sive.    They  may  be  found  in  text-books  of  neurology. 

Hysteria. — The  j^ains  of  hysteria  are  similar  to  those  of  neu- 
rasthenia. Pressure  sensibility  in  the  back,  over  one  or  more 
spinous  processes,  as  well  as  the  other  peculiarities  of  neuras- 
thenia, are  present  in  hysterical  back  pain. 

Traumatic  Neuroses. — If  the  trauma  strikes  the  spinal  col- 
umn directly  or  indirectly,  pain  which  hinders  the  patient  from 
making  active  movements  may  occur  in  the  involved  area. 

General  Summary. — It  is  even  far  more  difficult  to  draw  diag- 
nostic conclusions  from  the  character  of  spinal  pains  than  it  was 
from  headache  pains.  They  have  little  of  characteristic  pecu- 
liarities. The  nightly  exacerbation  of  luetic  pains,  as  a  single 
exception,  is  almost  the  only  one  pointing  directly  to  an  etiological 
factor.  In  spinal-cord  affections,  local  pain,  local  pressure  sensi- 
bility, and  radiating  pains  are  singly  or  in  combination  diagnostic 
criteria  of  value.  They  may  occur  separately,  but  are  usually 
found  together.  Diagnostic  conclusions  can  rarely  be  drawn  from 
the  severity  of  the  i)ains  alone.  The  highest  degree  of  radiating 
pain  is  found  in  caries  and  tumors  pressing  upon  the  spinal  cord, 
as  well  as  in  meningeal  apoplexy,  meningitis,  and  meningomyelitis. 
The  severity  of  the  pain  depends  more  upon  the  extent  and  the 
degree  of  the  process  than  on  its  nature,  so  that  the  intensity  of 
the  pain,  in  the  diseases  described,  may  be  greater  or  less,  accord- 
ing to  the  stage  of  the  disease.  It  should  be  observed  that  pains  in 
the  back,  along  the  entire  spinal  cord  or  a  greater  part  of  it,  in 
neurasthenia  are  almost  always  of  a  minimum  intensity,  though 
they  are  described  by  the  patient  as  being  very  severe.  Observa- 
tion of  the  patients,  however,  shows  that  they  are  bearable  pains. 


CORD    CONDITIONS    WHICH    CAUSE   PAIN  217 

In  most  cases  of  localized  spinal  affections  the  pains  are  not  spread 
out  over  the  entire  vertebral  column,  but  affect  only  circumscribed 
parts  of  one  or  a  few  vertebrae.  A  pain  limited  to  a  circumscribed 
area  frequently  is  valuable  for  a  diagnosis;  not  so  much  for  the 
recogTiition  of  the  trouble  itself,  as  for  the  determination  of  its 
location.  The  sudden  darting  pains  of  tabes  are  almost  pathogno- 
monic, as  are  also  the  crises  pains. 


CHAPTER  X 

PAIN  IN  THE  TISSUES 

MUSCULAR   TISSUES 

Muscles  are  subject  to  pain  and  seem  especially  to  be  affected 
in  the  acute  infectious  diseases,  or  in  those  conditions  which  go  by 
the  rather  loose  term  ''colds."  The  majority  of  these  diseases  are 
due  to  bacterial  invasion,  with  the  production  of  toxins,  and  it  is 
these  toxins  which  seem  to  have  a  selective  action  on  the  sensory 
nerve  receptors  distributed  in  the  muscles. 

For  a  long  time  it  was  not  definitely  known  that  sensory  nerve 
receptors  existed  in  muscular  tissue.  Sherrington,  however,  dem- 
onstrated the  existence  of  such  organs,  and  Head,  by  his  thorough 
technique,  showed  that  the  origin  of  deep  sensibility  was  undoubt- 
edly muscular  and  tendinous.  As  yet,  though  we  know  that  they 
exist,  the  sensory  end  organs  in  the  muscle  tissue  have  not  been 
definitely  isolated.  In  some  cases  these  end  organs,  or  sensory 
nerve  filaments,  become  hypersensitive.  The  hypersensitiveness 
may  be  confined  to  the  muscles  alone,  the  overlying  skin  being 
uninvolved  or  both  the  skin  and  muscle  may  be  involved.  Tender- 
ness of  the  muscles  may  be  elicited  by  grasping  them  between  the 
fingers,  or  by  making  pressure  on  them.  At  the  same  time  pinch- 
ing the  skin  may  give  no  reaction,  for  the  reason  that  the  deep  sen- 
sory system  may  alone  be  affected,  the  skin  systems  not  being  im- 
plicated. 

In  a  consideration  of  the  pain-producing  diseases  of  the 
muscles  it  is  better  to  divide  them  into  the  voluntary  and  invol- 
untary, for  what  would  produce  a  painful  reaction  in  the  volun- 
tary often  has  absolutely  no  effect  in  involuntary  muscle;  for 
218 


MUSCULAR   TISSUES  219 

instance,  inflammation  in  voluntary  muscle  gives  rise  to  very- 
severe  pain,  while  in  involuntary  muscle  it  may  not  produce  the 
least  sign  of  its  presence.  In  either  case  the  stimuli  which  react 
to  cause  pain  are  the  same,  but  those  in  the  voluntary  muscles 
act  upon  sensory  termini  which  are  accustomed  to  respond  to 
inflammatory  irritative  stimuli  by  pain,  while  in  the  involuntary 
muscle  the  sensory  termini  have  had  no  such  training,  and  react 
only  in  response  to  an  entirely  different  set  of  stimuli.  In  the 
voluntary  muscles  the  pain  syndrome  may  be  produced  in  a 
flaccid  muscle  by  the  action  of  bacterial  toxins  on  a  sensory  nerve 
terminal,  while  in  the  intestine  it  is  necessary  that  to  the  bacterial 
invasion  a  contraction  of  the  muscle  fibers  also  be  added  before 
pain  is  produced. 

A  condition  in  which  all  voluntary  movements  have  been  asso- 
ciated with  great  pain  has  been  described  by  McCarthy  (Osier's 
System,  VI,  569).     He  terms  it  Akinesia  Algera. 

VOLUNTARY    MUSCLES 

The  diseases  of  voluntary  muscle  causing  pain  are  myositis, 
acute  polymyositis,  myositis  fibrosa,  myositis  ossificans  and  my- 
algia. 

Myositis.  — When  inflammation  of  a  muscle  (myositis)  occurs, 
the  pain  is  found  in  definite  areas  corresponding  to  the  muscular 
distribution.  The  pain  may  be  so  severe,  and  every  movement 
so  provocative  of  pain,  that  the  patient  is  unable  to  move,  and 
lies  in  bed  like  one  paralyzed.  Different  groups  of  muscles  may 
become  involved  successively.  The  involved  muscles,  as  a  rule, 
are  greatly  swollen.  The  pains  are  described  as  drawing,  tear- 
ing, or  boring  (Steiner).  In  other  cases,  no  definite  inflamma- 
tory state  can  be  defined,  but  severe  pain  is  produced  on  move- 
ment of  a  certain  gToup  of  muscles.  This  is  very  common  in 
women  of  feeble  muscular  development,  and  is  ^'felt  at  the  attach- 
ments of  the  abdominal  muscles  to  the  ribs,  or  along  the  attach- 
ments of  the  erectors  of  the  spine.  These,  in  reality,  are  stretching 
pains,  and  are  due  to  an  abnormal  pull  upon  the  tendinous  struc- 


220  PAIN    IN   THE    TISSUES 

tures  from  deficient  muscular  support"  (Thompson,  36).  In 
these  cases  the  skin  may  be  verj  hypersensitive  over  the  insertion 
of  the  involved  muscles  (Moullin,  226).  In  other  cases  pain  is 
present  in  the  skin  over  the  entire  extent  of  the  involved  muscle. 
This  would  seem  to  lend  credence  to  that  part  of  Hilton's  law 
which  states  that  skin  over  involved  muscles  is  tender  in  disorders 
of  these  muscles,  because  both  have  the  same  nerve  supply.  This 
cannot  always  be  true,  however,  because,  as  already  explained, 
while  the  muscle  and  overlying  skin  might  originally  have  been 
supplied  by  the  same  nerve  or  nerves,  yet,  owing  to  development 
and  consequent  change  in  the  relative  position  of  both  the  skin  and 
its  underlying  muscle,  it  frequently  happens  that  the  skin  is  dis- 
placed to  a  considerable  distance  away  from  its  original  position 
over  its  nerve-related  muscle. 

Of  the  acute  forms  of  myositis  the  suppurative  variety  soon 
lends  itself  to  ready  diagnosis,  not  from  the  pain,  which  at  first 
resembles  that  of  a  generalized  neuralgia,  or  is  of  a  rheumatic 
type,  but  from  the  rapid  localization  in  the  involved  muscle  of 
the  characteristic  tender  indurative  swellings,  hard  and  board-like 
in  character.  Muscular  contractures  are  the  rule.  Softening  and 
fluctuation  soon  determine  the  true  nature  of  the  pain.  Suppura- 
tive myositis  may  be  multiple  or  isolated. 

Acute  Polymyositis. — The  form  of  myositis  which  has  just 
been  discussed  is  largely  a  local  affair  affecting  one  muscle  or  a 
small  group  of  closely  related  muscles.  In  persons  of  early  or 
middle  life  there  exists,  however,  a  form  of  acute  generalized  in- 
flammation of  the  muscles — a  polymyositis — in  which  pain  is  a 
prominent  symptom. 

This  disorder,  frequently  a  complication  of  other  infectious 
disease,  also  of  generalized  toxemic  states,  usually  begins  with 
acute  constitutional  symptoms,  malaise,  headache,  nausea,  vomit- 
ing. Dragging  pains  then  occur,  with  frequent  cramps  in  the 
entire  musculature.  At  first  the  sore  spots  are  fairly  well  local- 
ized, tender  to  pressure  and  to  passive  motion.  Then  a  period  of 
inflammatory  edema  makes  its  presence  manifest  by  swelling  and 
hardness  of  the  parts.     These  swellings  may  at  times  give  the 


MUSCULAR    TISSUES  221 

muscles  a  somewhat  grotesque  appearance.  The  skin  is  tense, 
often  reddened,  and  may  show  exanthemata,  erythema,  urticaria, 
or  vesicles.  The  electrical  excitability  diminishes,  and  atrophy 
takes  place  after  the  hypertrophy  has  disappeared.  The  epicritic 
sensibility  is  unimpaired.  Careful  search  should  always  be  made 
of  the  blood  picture,  as  certain  forms  of  polymyositis  are  associated 
with  eosinophilia,  which  not  infrequently  has  as  its  underlying 
cause  a  localized  or  generalized  trichinosis.  Other  parasites  are 
described. 

Myositis  Hsemorrhagica. — In  myositis  hsemorrhagica  pain  is 
the  first  symptom.  It  is  usually  sharply  circumscribed  to  a  spot 
in  the  muscle  where  a  small  nodular,  palpable  tumor  usually  de- 
velops. Edema  soon  sets  in  and  hemorrhagic  areas  are  observed, 
which  soon  show  the  familiar  yellow-green  discoloration. 

Myositis  Fibrosa. — Myositis  fibrosa  often  shows  itself  in  sharp 
pains  in  the  muscles,  the  lower  extremities  usually  being  first  im- 
plicated. The  disorder  advances  slowly,  going  from  one  muscle 
to  another,  and  the  patient,  after  several  months  or  years,  is  un- 
able to  move  about  because  of  the  pain  and  rigidity.  Contractures 
occur,  but  sensory  disturbances  are  rare.  Palpation  is  usually 
painless  in  this  particular  variety,  and  much  weight  is  laid  by 
Lorenz  upon  this  feature  in  diagnosis.  The  muscles  get  harder, 
but  the  spontaneous  pains  become  less  pronounced. 

Myositis  Ossificans. —In  myositis  ossificans  the  pain  often 
masks  the  case  as  one  of  ^'rheumatism."  In  some  pain  is  lacking 
in  the  early  stages.  The  usual  signs  of  myositis  are  present  in 
most  cases,  with  radiating  pains.  Following  an  attack,  the  pain 
subsides,  but  the  muscles  remain  hard  and  indurated.  Other 
attacks  come  and  go,  the  indurations  becoming  harder  and  harder, 
until  bony  masses  are  evident.  The  disorder  is  found  most  fre- 
quently in  the  muscles  of  the  back  and  neck,  the  face  and  upper 
extremities  less  frequently,  while  the  muscles  of  the  lower  ex- 
tremities are  rarely  involved.  The  gradual  rigidities  that  develop 
with  the  deformities  are  very  striking. 

Myalgia. — Torticollis  and  lumbago  are  the  most  classical  of 
the  m^'algias,   although  any  muscle  of   the  body  may  show   this 


222  PAIN   IN   THE   TISSUES 

peculiar  disturbance.  Myalgias  are  very  frequent,  yet,  notwith- 
standing, the  cause  is  very  obscure.  Exposure  to  cold  and  trau- 
matism are  among  the  most  frequent  etiological  factors. 

The  pain  is  usually  sharp,  especially  when  the  parts  are  moved 
and  the  muscles  forced  to  functionate,  actively  or  passively.  In 
torticollis,  in  which  the  sternocleidomastoid  is  affected,  the  pa- 
tient holds  the  head  to  one  side,  and  the  pain  is  very 
severe  and  is  usually  unilateral.  In  lumbago  the  pain  is 
in  the  back.  The  onset  is  usually  sudden,  often  following  a 
muscular  strain ;  every  movement  becomes  extremely  painful,  and 
the  position  adopted  by  the  patient  is  very  characteristic.  He 
walks  with  a  stiff,  short  tread.  Lumbago  may  be  confused  with 
spinal  arthritis,  with  sacroiliac  disease,  with  malignant  spinal 
growths,  or  even  tuberculosis  of  the  spine.  Other  muscles  (pleu- 
rodynia, scapulodynia,  dorsodynia)  afford  other  special  pains  and 
special  postures. 

The  muscles  are  often  somewhat  painful  to  pressure,  and  occa- 
sionally they  are  indurated ;  at  times  the  induration  is  soft,  again 
it  is  hard.  Counterirritation  and  massage  often  relieve  the  con- 
dition very  rapidly. 

INVOLUNTAEY    MUSCLES 

Colics.  — Thus  far  only  voluntary  muscles  have  been  consid- 
ered. Involuntary  muscles,  also,  are  the  site  of  pain  sensation, 
especially  those  which  are  present  in  the  hollow  viscera.  Here 
the  pain  is  associated  with  contractures  or  spasms.  These  con- 
tractions or  spasms,  when  they  occur  in  the  intestinal,  genito- 
urinary, or  biliary  tracts,  are  called  colic.  The  pain  in  colic  is 
constant,  as  a  rule,  but  may  have  periods  of  greater  or  less  in- 
tensity. Of  all  colics,  perhaps,  that  of  the  common  gall-duct  is  the 
most  severe. 

Colicky  pains  show  variations.  In  some  cases  there  is  a  sudden 
increase  of  pain,  which  persists  for  a  longer  or  shorter  period  and 
suddenly  disappears.  In  another  type  the  colicky  pain  comes  on 
suddenly,  then  remits,  and  in  a  few  hours  returns  and  becomes 


MUSCULAR   TISSUES  223 

very  severe.  This  may  be  repeated  many  times.  In  a  third  variety 
the  pains  at  first  are  light,  but  become  of  gradually  increasing 
intensity,  with  an  incomplete  remission  between  the  paroxysms 
until  a  paroxysm  of  maximum  intensity  occurs,  when  there  is  a 
gradual  remission  and  return  to  the  normal. 

Several    factors    enter    into    the   causation    of    colicky   pain. 

(1)  The  pains  may  be  due  to  the  overdistention  of  a  portion 
of  the  canal  lying  between  a  distal,  non-moving,  contracted  part  of 
the  canal,  and  a  movable,  contracting  part,  the  movable  part  gradu- 
ally approaching  the  stationary  part  until  the  contents  in  the  in- 
tervening canal  are  put  under  great  pressure  and  consequent  dila- 
tation and  overdistention  of  the  canal  take  place.  This  over- 
distention causes  a  stretching  and  pressure  on  the  nerve  terminal 
filaments  in  the  wall,  and  pain  results.  Normally  this  overdisten- 
tion does  not  occur,  for  it  is  a  rule,  in  all  hollow  muscular  viscera, 
that  contraction  of  one  portion  is  followed  by  relaxation  of  the 
next  adjacent  portion.  It  is  only  when  this  law,  called  by  Meltzer 
(105b)  the  "law  of  contrary  innervation,"  is  at  fault  that  colic 
occurs. 

(2)  Pressure  may  be  made  upon  the  terminal  nerve  fila- 
ments by  the  contracting  muscles. 

(3)  Traction  and  pull  is  made  on  the  mesentery  by  the  in- 
equality in  position  of.  the  contracted  and  noncontracted  seg- 
ment. 

(4)  During  contraction  of  the  bowel  it  tends  to  straighten 
out  and  this  causes  a  pulling  and  stretching  of  the  mesentery. 
In  fact,  it  seems  that  this  is  the  most  reasonable  hypothesis.  This 
is  contrary  to  the  idea  of  Hertz  that  tension  is  the  only  true 
cause  of  hollow  visceral  pain.  In  intestinal  colic,  relief  almost  at 
once  follows  the  onward  passage  of  the  feces.  The  pain  of  intes- 
tinal colic  is  not  felt  so  much  in  the  viscera,  but  is  referred  to 
the  anterior  abdominal  body  wall,  and  follows  the  law  of  seg- 
mental distribution  (Head).  Hertz,  on  the  contrary,  claims  that 
the  referred  pain  is  rarely  present  alone  to  the  exclusion  of  a  true 
visceral  pain,  but  that  the  visceral  pain  is  often  present  to  the  ex- 
clusion of  the  referred  pain. 


224  PAIN   IN    THE   TISSUES 

FATTY    TISSUES 

Adiposis  Dolorosa.  — In  this  condition,  first  described  by  Der- 
cum  in  1888,  pain  is  a  prominent  feature.  It  is  a  pain,  however, 
that  is  more  the  result  of  pressure  than  spontaneous,  although  there 
usually  are  burning,  lancinating  sensations  present  in  the  fatty 
masses,  which  form  the  characteristic  features  of  the  disease. 

Diffuse  collections  of  fat,  scattered  over  the  body,  are  found 
in  several  conditions.  Adiposity  sliows  itself  under  several  forms ; 
chief  of  these  are  the  adiposis  tuberosa  of  Anders,  adiposis  cere- 
bralis  of  Frohlich,  formerly  prophyseal  or  epiphyseal  disease 
(Marburg,  Jelliffe),  symmetrical  adenolipomatosis,  multiple  lipo- 
matosis and  adiposis  dolorosa.  These  are  probably  closely  related 
conditions,  and  pathologically  some  relationship  to  the  ductless 
glands,  particularly  the  hypophysis,  is  probable. 

Adiposis  dolorosa  varies  from  the  others  by  reason  of  the  pain 
and  tenderness  of  the  fatty  masses.  This  pain  is  probably  the  re- 
sult of  an  associated  neuritis,  since  neuritic  lesions  have  been  found 
in  a  number  of  cases.  Furthermore,  tender  nerve  trunks,  trophic 
changes,  and  sensory  symptoms  go  to  round  out  the  picture  of  a 
neuritic  involvement. 

The  fatty  areas,  as  they  develop  on  a  basis  of  a  general  adipos- 
ity, are  usually  edematous  and  tender.  Pressure  induces  an  ex- 
quisite painfulness,  and  leaves  behind  it  burning,  lancinating 
sensations.  The  areas  have  a  tendency  to  disappear,  leaving  in- 
durated spots;  then  recurrences  take  place,  and  nodular  tumors 
develop.  These  nodules,  which  are  very  sensitive — even  to  the 
slightest  touch — often  giving  rise  to  exquisite  pain,  are  found 
principally  over  the  trunk  and  extremities.  The  face,  hands  and 
feet  are  free.  Cases  are  also  met  with,  with  no  nodules.  Here 
there  are  large  indurative  areas,  sensitive  to  touch  and  palpation. 
There  is  a  tendency  for  these  areas  to  become  less  sensitive,  but 
nodules  "which  remain  in  the  fat  retain  an  exquisite  tenderness, 
and  are  the  centers  for  neuralgic-like  radiating  pains. 

Pain  is  present  usually  at  all  times.  It  may  be  an  initial 
symptom,  coming  on  before  there  are  any  fatty  nodules.     It  may 


PATTY   TISSUES  225 

be  dull,  lancinating,  or  burning;  rarely  is  sharply  localized  to 
any  nerves,  but  is  usually  associated  with  tender  nerve  trunks. 

Asthenia,  querulous  irritability,  mental  apathy,  and  depres- 
sion are  frequent  associated  conditions,  while  general  neuritic 
signs,  such  as  anesthesiae,  hyperesthesia,  vasomotor  disturbances, 
hypersecretion,  cyanosis,  demographia,  ulcers,  ecchymoses,  all  con- 
tribute to  the  general  evidence  to  show  some  implication  of  the 
protopathic  system. 

In  all  cases  of  adiposis  dolorosa  examination  should  be  made 
for  hypophyseal  symptoms.  In  many  cases  of  this  disease  an 
adenoma  of  the  posterior  lobe  of  the  hypophysis  has  been  found 
(Pick). 


CHAPTER  XI 

BONE  PAINS— THE  OSTALGIAS 
GENERAL    CONSIDERATIONS 

When  pain  occurs  in  a  limb  over  a  region  where  bone  involve- 
ment is  a  possibility,  it  is  necessary  to  consider  lesions  of  struc- 
tures overlying  the  bone,  as  well  as  those  of  the  bone  itself.  It 
is  only  when  pathological  lesions  in  the  overlying  structures  have 
been  eliminated  that  the  bone  should  be  considered  as  at  fault. 
When  a  patient  complains  of  pain  in  bony  structures  it  is  neces- 
sary first  to  obtain  a  history  of  the  pain,  its  type,  manner  of  onset 
and  character,  and  then  to  proceed  to  a  physical  examination  of 
the  affected  region.  Of  the  physical  methods  of  examination 
made  use  of  in  the  elucidation  of  bone  symptoms,  palpation  is 
productive  of  the  best  results.  If  palpation  over  a  limb  or  a  part 
where  bone  is  a  prominent  structural  component  discloses  only 
superficial  pain,  the  bone  can  be  disregarded  as  the  chief  cause 
of  the  pain;  yet  it  should  always  be  borne  in  mind  that  a  lesion, 
which  at  first  may  have  commenced  in  the  bone,  may  progress  so 
that  adjacent  tissues  are  involved  and  secondary  lesions  ensue. 
These  may  be  far  worse,  and  produce  symptoms  of  much  greater 
severity  than  the  original  disorder,  so  that  often  in  the  medical 
survey  the  secondary  lesion  intrudes  itself  to  such  a  degree  that 
the  original  primary  condition  is  overlooked.  As  a  rule,  however, 
if  tenderness  and  pain  are  both  superficial,  and  there  is  no  his- 
tory of  a  previous  deeper  pain,  the  bone  may  be  disregarded  and 
the  superficial  tissues  considered  as  being  at  fault  (bone  lesions 
are  tender  and  painful  on  deep  pressure). 
226 


TYPES    OF   PAIN  227 

TYPES    OF    PAIN 

In  our  examination  as  to  the  cause  of  the  bone  pain,  inquiry 
must  be  made  as  to  its  type,  i.e.,  whether  it  is  continuous  or  inter- 
mittent. 

Continuous  pains  are  due  to  persistent  acting  causes,  such  as 
new  growths,  inflammation  or  aneurysm.  New  bony  growth  gen- 
erally produces  a  dull,  aching  pain,  which,  as  a  rule,  is  fairly  well 
localized  to  the  area  affected.  Inflammation  of  bone  produces 
a  continuous  pain,  which  is  interrupted  at  times  by  paroxysms 
of  greater  intensity.  Pressure  on  a  bone  by  a  growing  tumor  or 
an  aneurysm  (with  gradual  erosion  of  the  bone)  causes  a  dull, 
aching  pain  of  great  severity.  In  this  condition  there  is  a  sharply 
defined  area,  exquisitely  tender  to  the  touch,  corresponding  to 
the  site  of  the  bone  involvement.  Other  signs  of  tumor  or 
aneurysm  are  also  present. 

Intermittent  pain  in  bony  lesions  is  divided  into  two  classes ; 
in  the  first,  the  pain  occurs  spontaneously,  without  any  excess  of 
local  irritation,  and  generally  indicates  a  more  severe  process  than 
in  the  cases  where  pain  is  felt  only  on  pressure.  When  pain  is 
only  felt  on  pressure  (if  the  bone  is  only  slightly  involved)  it 
disappears  from  the  part  as  soon  as  the  pressure  is  removed ;  but 
in  more  severe  cases  it  may  persist  for  some  time  after  the  re- 
moval of  the  pressure. 

In  some  cases  there  are  recurring  attacks  of  very  violent 
pain,  with  great  tenderness  at  the  point  where  the  pain  is  felt. 
When  this  pain  and  tenderness  are  accompanied  by  local  swell- 
ing, fever,  and  a  rapid  pulse,  osteomyelitis  should  be  considered. 
Pains  of  this  type,  spontaneously  occurring  at  intervals  without 
any  apparent  existing  causes,  are  called  spontaneous  intermittent 
pains.  The  other  forms  which  can  be  produced  by  pressure  are 
called  pressure  intermittent  pains.  These  occur  generally  in 
association  with  an  inflammation  and  are  either  mild  or  severe, 
depending  upon  the  amount  of  pressure  which  it  is  necessary  to 
exert  on  the  part  to  produce  pain.  Among  the  pressure  intermit- 
tent pains  are  those  due  to  osteomalacia  and  osteomyelitis. 


228  BONE   PAINS— THE    OSTALGIAS 

Diurnal  variation  of  the  pains  is  of  great  value  in  the  diag- 
nosis of  bone  lesions.  Pains  due  to  certain  diseases  seem  to  appear 
at  regular  and  definite  periods  of  the  day.  Syphilitic  and  tubercu- 
lous bone  pains  are  generally  worse  at  night.  A  point  of  impor- 
tance is  that  luetic  pains  are  always  relieved  by  mercury  and  the 
iodides,  and  tuberculous  lesions  give  tuberculin  reactions  and  the 
serological  test  (Wassermann's)  is  present  in  lues.  Kocturnal 
ostalgia  is  very  common  in  typhoid  fever,  especially  in  patients  in 
whom  the  bone  marrow  is  involved,  so  that  when  a  limb  pain  is 
present  in  those  convalescing  from  typhoid  fever  the  bone  should 
always  be  examined.^ 

CHARACTER    OF    BONE    PAIN 

According  to  its  severity  bone  pain  may  be  classified  as  sharp, 
piercing,  dull,  or  aching.  When  the  pain  is  sharp,  it  is  generally 
of  sudden  onset,  and  comes  without  warning.  If  it  is  very  severe, 
and  is  sharply  localized,  osteomyelitis  is  most  likely  to  be  present. 
Piercing  pain  is  not  common  in  bone  disease,  and,  when  present, 
neuralgia  should  be  sought. 

Dull  and  aching  pain  is  characteristic  of  syphilitic  lesions. 
When  present  an  examination  for  past  or  present  syphilis  should 
be  made.  It  is  also  present  in  periostitis,  in  which  at  the  point 
of  periosteal  thickening  a  dull  pain,  with  at  times  more  or  less 
acute  exacerbation,  is  felt.  When  the  periosteum  is  diseased,  a 
well-marked,  localized  thickening  will  be  found  on  X-ray  exami- 
nation. 

LOCALIZED    BONE    PAIN 

With  reference  to  extent,  bone  pains  may  be  classified  either  as 

localized  or  diffuse.     Localized  bone  pains  are  due  to  periosteal 

lesions,  traumatism,  new  growths,  and  inflammation. 

1  It  seems  that  the  medulla  of  bone,  perhaps  the  endosteum,  is  much  more 
sensitive  than  the  periosteum,  for  recently  in  our  (Dr.  Sehultze  and  myself) 
work  on  bones  we  have  found  that  the  cutting  of  the  periosteum  or  the  tre- 
phining of  the  cortex  was  not  especially  noticed  by  the  morphinized  dog,  but 
as  soon  as  the  drill  penetrated  the  medullary  cavity  he  became  restless  and 
whined  very  much.  Later  in  the  experiment,  when  it  became  necessary  to  in- 
troduce a  sound  or  curette  into  the  narrow  cavity,  he  again  showed  signs  of 
apparent  pain. 


LOCALIZED    BONE   PAIN  229 

Periosteal  Lesions. — The  periosteal  lesions  causing  pain  are, 
as  a  rule,  inflammatory.  If  the  inflammatory  changes  occur  at  the 
point  of  the  insertions  of  muscles  or  tendons,  any  activity  of  the 
muscles  or  movement  of  the  tendons  will  cause  pain,  and  in  some 
*ases  this  may  be  confused  with  pain  produced  in  the  bone  itself. 
In  periosteal  inflammation  tenderness  is  sharply  limited,  which,  as 
a  rule,  is  not  the  case  in  lesions  of  the  bone  itself.  The  tender- 
ness is  nicely  defined  by  running  the  finger  down  to  and  over  the 
inflamed  area.  In  lesions  of  superficial  bones  like  the  tibia 
marked  pain  is  evinced  as  soon  as  the  finger  crosses  the  border  of 
the  inflamed  area. 

Should  swelling  of  the  periosteum  occur  without  pain,  it  may 
be  due  to  a  new  growth  which  causes  pain  only  when  the  sub- 
periosteal distention  becomes  so  great  that  pressure  is  made  upon 
the  sensory  nerve  filaments  terminating  in  the  periosteum. 

In  children  the  so-called  growing-out  pains  are  often  the  result 
of  slight  septic  processes  in  the  periosteum.  They  often  appear 
after  acute  infection,  tonsillitis,  etc. 

Traumatism. — Here  the  pain  is  of  sudden  onset  and  immedi- 
ately follows  the  injury.  If  the  part  is  too  tender  to  palpate,  an 
anesthetic  may  be  used,  so  that  a  proper  diagnosis  of  the  condi- 
tion can  be  made.  If  possible  a  skiagraph  of  the  part  should  be 
taken.  This  will  save  considerable  manipulation  of  the  injured 
region,  and  will  lessen  the  necessary  pain  to  the  patient.  If  the 
X-ray  is  not  available  the  presence  or  absence  of  fracture  should 
be  determined  from  crepitus  and  false  motion.  If  a  fracture  is 
found  its  probable  direction  and  extent  should  also  be  determined. 
Following  an  injury,  if  localized  tenderness  is  present  and  the 
bone  has  not  been  broken,  bruises  and  contusions  must  be  consid- 
ered. These  may  also  occur  in  the  periosteum,  in  which  case  the 
tenderness  is  present  as  a  rule  only  on  deep  pressure.  It  is  neces- 
sary to  consider  fractures,  bruises  and  contusions  separately.  In 
some  severe  injuries  all  these  may  be  included  in  one  lesion,  which 
is  called  a  crush. 

Fracture. — In  fractures  pain  may  be  entirely  or  almost  en- 
tirely absent,  particularly  when  the  fracture  is  an  impacted  one. 


230  BONE   PAINS— THE   OSTALGIAS 

This  occurs  only  in  the  absence  of  laceration  of  the  adjacent  parts. 
Pain  may  also  be  absent  when  the  fractured  ends  of  the  bone  are 
separated  by  a  considerable  interval.  In  fractures  pain  is  elicited 
by  two  methods :  First,  by  passive  motions,  to  produce  which  the 
limb  is  grasped  so  that  one  hand  is  above  the  line  of  fracture  and 
the  other  below  it,  and  to  and  fro  movement  is  made  so  that  there 
is  motion  between  the  fragments ;  when  a  fracture  is  present,  pain 
is  felt,  sharply  localized  at  the  point  of  fracture.  Second,  if  pres- 
sure be  now  made  over  the  point  of  greatest  pain,  a  well-marked 
area  of  tenderness,  corresponding  rather  closely  to  the  line  of 
fracture,  is  found.  In  some  fractures  the  line  of  the  fracture  may 
be  outlined  by  the  sharply  defined  area  of  tenderness  immediately 
above  it.  This  line  of  tenderness  is  very  useful  in  diagnosing  a 
greenstick  fracture  in  which  crepitation  and  false  movement  are 
absent.  In  certain  cases  of  impacted  fractures,  for  instance,  those 
of  the  femur,  gi'eat  care  should  be  exercised  in  the  manipulations, 
so  as  not  to  break  up  the  impaction ;  otherwise,  especially  in  old 
people,  a  condition  in  which  union  does  not  occur  will  result.  A 
point  of  considerable  importance  to  remember  in  the  diagnosis  of 
fracture  is  that  tenderness  persists  for  a  considerably  longer  period 
in  a  fracture  than  in  a  simple  contusion.  If  the  pelvis  should  be 
injured  and  a  fracture  suspected  the  crests  of  the  ilium  should  be 
forcibly  pressed  toward  the  middle  line.  When  a  fracture  is  pres- 
ent there  is  a  well-marked  and  sharply  defi.ned  pain  at  the  point 
of  fracture. 

Contusions. — Bruises  and  contusions  generally  are  the  result 
of  direct  violence,  and  are  localized  in  extent.  The  periosteum  is 
markedly  elevated  and  under  it  a  blood  clot,  felt  as  a  soft,  fluctu- 
ating mass,  may  be  present.  If  in  a  lesion  of  this  kind  in  which 
the  swelling  is  beneath  the  periosteum  the  pain  increases,  instead 
of  decreases,  it  is  likely  that  infection  has  occurred,  particularly 
if  the  swelling  continues  to  increase  in  size  and  becomes  softer. 

New  Growths. — As  a  rule,  new  growths  of  bone  are  not  pain- 
ful (  ?)  until  the  periosteum  is  involved,  or  until  pressure  is  made 
upon  adjacent  tissues,  when  they  give  rise  both  to  local  and  re- 
ferred pain.     Resembling  new  growths,  tuberculous  disease  of  the 


LOCALIZED    BONE    PAIN  231 

bone  may  be  present  for  some  time  without  producing  pain,  but, 
as  a  rule,  it  soon  gives  rise  to  a  dull  aching,  which,  if  the  adja- 
cent joint  is  involved,  is  interrupted  by  sharp  paroxysms. 

Septic  Involvement. — Septic  involvement  of  the  osseous  sys- 
tem is  frequently  encountered  during  pneumonia  and  malaria.  It 
also  is  common  during  the  course  and  convalescence  of  typhoid 
fever,  the  bones  must  frequently  affected  being  the  ribs,  tibia, 
femur  and  clavicle.  This  septic  involvement,  and,  in  fact,  all  in- 
flammatory changes,  can  occur  only  in  the  bone  marrow  and 
the  cancellous  tissue,  because  the  hardness  and  density  of  the  cor- 
tex inhibit  iuflammatory  reactions.  To  these  inflammatory 
processes  the  name  osteomyelitis  has  been  given.  The  pain  of 
acute  osteomyelitis  is  of  the  greatest  intensity.  According  to 
JSTichols,  it  is  the  most  intense  of  any  pain  with  which  we  are 
familiar.  Osteomyelitis  of  the  long  bones  often  commences 
with  a  sharp,  sudden  j^ain  in  the  vicinity  of  the  epiphyseal  line. 
A  sign  of  great  significance  in  the  diagnosis  of  osteomyelitis  is  that 
continued,  gentle  pressure  on  the  shaft  of  the  bone,  at  a  distance 
from  the  area  of  greatest  pain,  will  at  first  produce  no  pain,  and 
then,  very  suddenly,  there  will  occur  a  sudden  short  exacerbation 
of  great  severity.  Acute  osteomyelitis  generally  gives  acute  symp- 
toms, but  it  must  not  be  forgotten  that,  either-  following  such  an 
acute  attack  or  arising  de  novo,  a  chronic  osteomyelitis  may  be 
present  and  give  rise  only  to  a  dull  aching,  in  some  cases,  gnawing 
pain  in  the  affected  area. 

Changes  in  the  structure  of  a  bone  not  only  may  be  the  result 
of  germ  infection,  but  may  also  be  produced  by  diseases  of  the 
hemopoitic  system,  such  as  leukemia  and  pseudoleukemia.  In 
such  conditions  pain  is  frequently  present  in  the  lower  part  of  the 
steruum.  It  is  produced  by  pressure  against  the  bone.  Such  pres- 
sure may  occur  while  leaning  against  the  edge  of  a  table,  in  writ- 
ing, on  resting  on  the  window-sill,  or  on  bending  over  the  washtub. 
Pain  of  this  tyi^e  is  often  the  first  manifestation  of  leukemia  or  of 
a  pseudoleukemia. 

Schmidt  has  made  the  interesting  observation  that  in  leukemia 
and  pseudoleukemia  the  sternal  pains  are  controlled  by  arsenic, 


232  BONE   PAINS— TPIE    OSTALGIAS 

and  that  during  the  period  of  greatest  activity  of  arsenic  the  pains 
are  less  troublesome.  He  has  also  found  that  the  bone  pains  in- 
crease and  decrease  with  the  increase  and  decrease  in  the  number 
of  the  leukocytes. 

GENERALIZED    BONE    PAIN 

The  diseases  causing  generalized  bone  involvement  and  giving 
rise  to  pain  are :  Osteomalacia,  diseases  of  the  hemopoitic  system, 
and  new  or  abnormal  growths. 

Osteomalacia  occurs  most  frequently  in  association  with  preg- 
nancy. The  2^^111  is  usually  found  in  the  lumbar  region  and  in 
the  lower  extremities.  It  is  produced  by  any  action  which  causes 
motion  in  the  affected  bones.  Such  actions  as  walking,  stooping, 
rising  from  a  sitting  to  a  standing  posture,  laughing,  sneezing  and 
coughing  produce  great  distress.  Schmidt  w^ell  describes  it  thus : 
"On  getting  out  of  bed,  the  patient  subject  to  osteomalacia  care- 
fully lifts  out  each  leg  in  turn,  holding  it  by  the  thigh."  Deep 
respiration  often  gives  rise  to  pain  in  the  ribs.  Descent  of  the 
stairs  is  sometimes  more  uncomfortable  than  the  ascent,  because 
of  the  jarring  of  the  body  that  it  occasions.  While  moving  about 
is  exceedingly  arduous,  remaining  in  the  same  position  for  any 
length  of  time,  either  sitting  or  lying,  results  in  an  increase  of  the 
pain.  The  patients  are  thus  obliged  to  change  their  jDositions 
constantly,  and  their  sleep  is  very  broken.  ,  Abduction  as  Avell  as 
rapid  dorsal  flexion  of  the  hip  causes  paroxysms  of  pain  located  at 
the  ankle  joint.  In  the  latter  case  the  pain  often  runs  the  entire 
length  of  the  lower  extremity,  radiates  to  the  pelvis,  and  is  some- 
times accompanied  by  dorsal  clonus.  Lateral  compression  of  the 
thorax,  or  of  the  pelvis  at. the  level  of  the  trochanters  or  iliac  crest, 
promptly  causes  pain.  The  wearing  of  a  corset  and  tight  lacing 
sometimes  appear  to  relieve  the  subjective  symptoms,  evidently 
through  the  support  given  to  the  spinal  column.  Osteomalacia 
should  be  carefully  diagnosed  from  spondylitis  of  the  dorso-lumbar 
region,  in  which,  during  the  early  stages,  the  character  of  the' 
pain  may  be  somewhat  similar. 


DIFFERENTIAL    DIAGNOSIS    OF    BONE    PAIN  233 

Diseases  of  the  hemopoitic  system,  as  leukemia  and  pseudoleu- 
kemia, also  cause  aching  pains  in  the  long  bones.     (See  above.) 

New  growths  of  bone  are  sarcoma,  carcinoma,  myeloma, 
lymphadenoma  ossium,  and  chloroma. 

Sarcoma  and  Carcinoma. — Should  pains  be  associated  with  a 
tumor  mass  and  at  the  same  time  with  cachexia,  search  should  be 
made  for  malignant  bone  disease,  and  one  of  the  best  methods  of 
diagnosis  is  the  X-ray.  In  suspected  cases  the  adjacent  lymph 
glands  should  also  be  examined  for  swelling  and  the  skin  should 
bo  inspected  for  the  red  lines  caused  by  affected  lymph  radicles 
(running  from  the  site  of  the  disease  to  the  nearest  lymph  gland). 

Myeloma,  lymphadenoma  ossium,  and  chloroma  cause  diffuse 
pain  and  are  associated  wdth  the  symptoms  of  internal  lesions. 
Malignant  metastatic  growths  also  are  frequently  found  in  bone, 
and  cause  pain  which  at  first  may  be  delimited  and  localized ;  but 
finally,  with  the  involvement  of  the  entire  bone,  the  pain  also 
becomes  diffuse. 

Abnormal  growths  of  bone  causing  jiain  are  osteitis  deformans, 
and  leontiasis  ossea. 

Osteitis  Deformans. — In  case  of  long-continued  pain  in  the 
legs,  with  occasionally  tender  points  over  the  bone,  osteitis  de- 
formans, or  Paget's  disease,  may  be  found.  Its  presence  is  further 
indicated  by  the  constantly  increasing  size  of  the  head. 

Leontiasis  ossea  is  also  a  rather  frequent  cause  of  bone  pain. 

Spurs  growing  out  from  bone  are  also  a  cause  of  pain.  When 
they  grow  out  of  the  os  calcis,  they  are  often  the  cause  of  the 
so-called  painful  heel. 

DIFFERENTIAL   DIAGNOSIS    OF    BONE    PAIN 

Bone  pain  should  be  differentiated  from  that  due  to  bursitis,  in 
which  a  painful  swelling  is  located  over  the  site  of  a  bursa.  Pain 
is  i^resent  only  in  acute  bursitis.  In  the  chronic  form  it  is  absent 
unless  an  acute  process  is  engrafted  upon  the  chronic  one.  Of 
somewhat  frequent  occurrence  are  the  neurotic  ostalgias,  the  so- 
called  functional  jDains.     In  some  cases  the  diagnosis  from  the  or- 


234  BONE    PAINS— THE   OSTALGIAS 

gallic  form  of  pain  is  very  difficult,  but  on  examining  under 
anesthesia  in  those  suffering  from  neurotic  ostalgia  no  loss  of  func- 
tion is  apjiarent  and  no  abnormal  change  in  the  tissues  can  be  felt. 
An  X-ray  examination  also  shows  no  pathological  change ;  at  the 
same  time  there  is  no  definable  change  in  the  relationship  of  the 
bone  to  the  surrounding  parts. 

Hysteria  may  be  differentiated  by  associated  areas  of  anes- 
thesia and  hyperesthesia,  as  well  as  by  the  eye  symptoms.  IN'erve 
lesions,  such  as  neuralgia  and  neuritis,  are  distinguished  by  their 
characteristic  symptoms.  Referred  nerve  pain  is  sometimes  pres- 
ent in  a  bone,  but  this  is  not  so  difficult  to  diagnose.  Local  symp- 
toms of  disease  are  absent,  while  diseased  areas  are  present  at 
a  distance.  Pains  may  also  be  referred  from  a  bone  to  a  distance ; 
such  pains  referred  are  often  found  in  diseases  of  the  vertebrae, 
however,  in  these  cases  pressure  over  the  spinal  column  is  very 

painful. 

JOINT   PAINS— ARTHRALGIA 

Classification. — Joint  pains  are  of  two  classes:  organic,  in 
which  the  pains  are  due  to  structural  changes,  and  non-organic, 
in  which  no  apparent  structural  change  can  be  found.  In  the 
former  the  pain  appears  when  the  affected  organ  begins  to  func- 
tionate. Under  the  latter  class  are  included  the  hysterical  and 
functional  pains. 

Organic  joint  pains  may  be  due  to  injury  or  to  disease  of  any 
one  or  more  of  the  following  structures:  namely,  the  bone,  car- 
tilage, sjTiovia,  capsules,  muscles,  tendons,  subcutaneous  tissues, 
and  the  skin.  The  pain  in  the  bone  may  be  due  to  involvement 
of  the  epiphysis,  in  which  case  it  is  elicited  by  direct  pressure  over 
the  epiphysis.  On  the  other  hand,  if  the  articular  cartilage  is  dis- 
eased, the  pain  is  best  elicited  by  suddenly  jolting  the  articular 
cartilages,  one  against  the  other.  If  pain  is  present  from  the  on- 
set of  the  swelling  in  a  moderatel^^  enlarged  joint,  and  then  if  a 
sudden  enlargement  of  the  joint  occurs,  with  a  concomitant  in- 
crease of  the  pain,  the  condition  is  most  likely  a  chronic  arthritis, 
with  an  acute  reinfection  and  consequent  synovitis.  If  such  is  the 
case,  it  is  accompanied  by  the  symptoms  found  in  p.cute  synovitis, 


JOINT    PAINS— ARTHRALGIA 


235 


such  as  a  rise  of  temperature,  chill,  and  marked  redness  of  the 
skin.     If  pain  and  swelling  are  found  first,  in  an  area  adjacent  to 


DELTOID 

SKIN  OVER  LOWER  PART  OF  OELTOIt) 
TERES  MINOK 


INTEGUMENT  OVER 
LOWER  TWO  THIRDS 
riBfrlMCi  r»/',"y    OELTOlO    LONG 
CIRCUMFLEX  /V  HEAD  OF  TRICEPS 


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CORACO  eRACHIALIS 
BRACHIAUS   ANTICU3 
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TO  f  LBOW  JOINT 


COMMUNICAT 
BRANCH  TO  PAlMA^ 
-COTANCOUS 
/    BR.  OF  MEDIA 


POST   BR 


MT.BR. 


5oppiie5  SKIN 

OVER  OUTtR  HALF 
OF   ANT.  SUMMt 


Fig. 


59. — Pain  in  Skin  Over  Back  and  Shoulder  Due  to  Disease  of 
Shoulder  Joint. 
In  this  drawing  of  the  brachial  plexus  is  shown  how  in  injuries  to  the  shoulder 
joint  the  pain  may  be  carried  back  through  the  suprascapular  and  circum- 
flex nerves  to  the  anterior  branch  of  the  fifth  cervical,  where  it  is  trans- 
ferred to  the  posterior  branch  of  the  fifth  cervical  and  thence  is  further 
propagated  backward  until  it  is  distributed  to  the  skin  over  the  back 
(trapezius  muscle) . 


the  joint,  and  then  spread  to  the  joint  and  cause  it  to  become  very 
much  swollen,  sensitive,  and  tender,  it  indicates  that  an  inflamma- 
tory process  has  extended  from  the  adjacetit  tissues  to  the  joint. 


236  BONE   PAINS— THE    OSTALGIAS 

causing  an  acute  arthritis.  Inflammatory  processes  of  this  nature 
are  characteristic  of  extension  from  an  osteomyelitic  area  in  the 
bone  into  the  joint,  and  also  of  an  inflammation  of  the  adjacent 
soft  parts,  such  as  occurs  in  erysij)elas,  abscess,  lymphangitis, 
and  bursitis  with  consequent  extension  into  the  joint. 
Osteomyelitis  is  tender  only  on  deep  pressure,  while  cutaneous 
and  subcutaneous  inflammation  is  exquisitely  tender  on  super- 
ficial pressure.  Inflammatory  changes  also  give  other  character- 
istic symptoms. 

Radiation  of  Joint  Pains. — Joint  pains,  as  a  rule,  do  not 
radiate.  There  are  few  exceptions,  however,  as  exemplified  in  the 
pain  of  the  knee  and  the  inner  side  of  the  leg,  which  occurs  in 
the  hip-joint  disease,  and  the  pain  in  the  aiikle  and  calf  of  the 
leg  present  in  flat  foot.  Pain  due  to  disease  of  the  shoulder  joint 
is  sometimes  felt  in  the  skin  over  the  back  and  shoulder  (see 
Fig.  59).  There  may  also  be  a  radiation  of  pain  to  joints.  This 
is  found  in  primary  or  associated  nervous  lesions,  as  tabes  or 
syringomyelia. 

Intensity  of  the  Pain. — The  intensity  of  the  pain  gives  some 
indication  of  the  rate  of  development  of  the  lesion,  for  it  has  been 
found  that  the  severity  of  the  pain  depends  to  a  great  extent  on 
the  suddenness  of  the  onset  of  the  disease ;  the  more  acute  the 
onset,  the  more  severe  is  the  pain.  The  reason  that  pain  is  not 
very  severe  in  disease  of  gradual  development  is  that,  in  this  type 
of  disease,  the  body  becomes  accustomed  to  the  pathological 
changes,  and  is  not  so  radically  affected  as  it  would  be  if  they  were 
of  sudden  origin.  Therefore  they  do  not  cause  such  sudden  re- 
adjustment of  tissues  and  consequently  do  not  cause  much  pain. 
When  joint  pains  are  of  extremely  sudden  onset,  they  are  usually 
the  result  of  an  acute  synovitis. 

Symptoms. — In  involvement  of  a  joint  the  pain,  as  a  rule,  i^ 
accompanied  by  certain  more  or  less  specific  symptoms,  such  as 
muscular  spasm,  and  swelling  or  loss  of  function  of  the  part 
affected.  In  deep  joints,  as  the  hip,  muscular  spasm  is  the  best 
indication  of  joint  trouble ;  whereas,  in  superficial  joints,  as  the 
knee,  swelling  is  the  surest  indication. 


JOINT    PAINS— ARTHRALGIA  237 

The  CESSATION  OF  FUNCTION  in  a  hypersensitive  joint  may  be 
explained  on  the  following  hypotheses : 

(1)  That  a  balance  exists  between  the  external  muscles  and 
the  internal  resistance  of  a  joint.  When  the  muscular  action  be- 
comes excessive,  and  too  much  pressure  is  exerted  upon  the  in- 
ternal structures  of  the  joint,  pain  is  produced.  This  inhibits 
further  action  of  these  same  muscles,  and  causes  inactivity. 

(2)  Where  excessive  pressure  is  j^resent,  there  also  seems  to 
be,  according  to  Hilton,  a  lessened  amount  of  synovial  fluid,  which 
produces  more  difficult  movement,  a  tendency  to  pain  production, 
and  a  consequent  inhibition  of  motion. 

(3)  Muscles  surrounding  or  associated  with  an  affected  or 
painful  joint  are  hypersensitive,  and  are  easily  thrown  into  con- 
traction, in  which  state  they  are  better  able  to  repel  any  attack 
upon  the  integrity  of  the  joint.  This  hypersensibility  also  causes 
them  to  contract  to  a  lighter  stimulus  than  usual.  In  some  cases 
the  slightest  touch  causes  the  most  pronounced  reaction. 

(4)  A  position  of  flexion  is  generally  taken  by  an  affected 
joint,  because  even  though  both  the  flexor  and  the  extensor  muscles 
are  equally  involved,  the  flexors  being  the  stronger,  overcome  the 
weaker  extensors,  and  draw  the  limb  into  the  position  of  flexion. 
It  is  possible  that  the  associated  tenderness  and  loss  of  muscular 
power  present  in  a  limb  in  which  the  joint  is  diseased  and  painful 
may  be  explained  by  the  association  of  the  nerve  supply  of  the 
joint  with  its  surrounding  muscles  and  overlying  skin.  From 
these  premises  Hilton  has  deduced  the  following  law:  The 
same  trunk  or  nerves  whose  branches  supply  the  groups  of 
muscles  moving  a  joint,  furnish  also  a  distribution  of  nerves  to 
the  skin  over  the  insertion  of  the  same  muscles,  and  the  interior 
of  the  joint  receives  its  nerves  from  the  same  source.  This  law 
does  not  always  apply,  for  it  has  been  partially  controverted  by 
Sherrington. 

After  the  patient  has  described  his  pain  and  its  characteristics 
it  is  necessary  to  verify  his  statements.  This  is  done  by  palpation 
and  manipulation.  Of  the  symptoms  resulting  from  manipulation 
the  most  important  one  is  tenderness.    In  all  inflamed  joints  this 


238  BONE   PAINS— THE    OSTALGIAS 

is  always  present.  It  is  also  M-ell  to  note  whether  the  tenderness 
is  superficial  or  deep.  If  superficial,  the  lesion  may  be  in  the  skin, 
muscles  (myalgia),  or  nerve  (neuralgia),  hut  if  it  is  deep  and  is 
noticed  only  on  deep  palpation,  it  indicates  that  the  lesion  is 
probably  associated  with  the  bones  forming  the  joint,  or  with  the 
synovial  membrane  of  the  joint  itself.  Then  if  the  tenderness  is 
not  too  great,  manipulation  of  the  joint  is  performed  (passive 
motion  being  made).  Some  idea  of  the  intensity  of  the  pain  may 
be  derived  from  the  resistance  to  motion.  Tenderness  in  a  joint 
may  also  be  elicited  by  knocking  the  opposing  joint  surfaces  to- 
gether with  a  sudden  shock.  If  they  are  denuded  or  inflamed, 
pain  is  produced.  Both  of  these  signs  can  be  elicited  in  the 
presence  of  fluid  if  the  quantity  is  not  too  large,  or  if  the  internal 
tension  is  not  too  great.  If  still  in  doubt  as  to  the  origin  of  the 
pain,  it  is  necessary  (after  all  these  diagnostic  means  have  been 
exhausted)  to  use  a  so-called  therapeutic  test.  Mercury  and  iodin, 
as  a  rule,  will  cause  syphilitic  joint  pains  to  cease,  and  salicylates 
ameliorate  those  due  to  rheumatism. 

Of  the  symptoms  associated  with  pain  in  joint  disease  swell- 
ing of  the  joint  and  eedness  are  the  most  important.  Redness 
usually  is  associated  only  with  acute  processes,  which  may  be  of 
two  kinds:  (1)  traumatic,  in  which,  in  addition  to  swelling  of  the 
joint  there  is  present  a  history  of  an  injury;  (2)  infectious,  when 
infection  is  added  to  traumatism,  the  pain  and  swelling  increase 
and  fever  makes  its  appearance.  If,  following  traumatism,  there 
occur  in  a  joint  pain  and  sw^elling,  it  indicates  that  an  acute 
synovitis  has  developed.  If  fever  is  also  present,  infection  should 
be  thought  of,  and  septic  organisms  should  be  sought.  In  cases  of 
subacute  urethritis,  the  gonococcus  is  a  frequent  cause  of  joint  in- 
volvement. However,  gonorrheal  arthritis  should  always  be  con- 
sidered in  case  of  an  apparent  idiosyncratic  inflammation  in  the 
joint,  when  it  is  borne  in  mind  that  septic  involvement  of  a  joint, 
without  external  communicating  injury,  is  very  rare,  and  that 
when,  in  the  presence  of  gonorrhea,  joint  involvement  occurs,  the 
gonococcus  is  probably  the  causal  agent.  In  gonorrheal  arthritis 
the  pain  is  slight  at  first,  and  is  accompanied  by  swelling  and  stiff- 


JOINT    PAINS— ARTHRALGIA  239 

ness  of  the  joint,  with  a  slight  temperature.  A  history  of  such 
joint  difficulty  may  also  show  that  the  joint  symptoms  followed  the 
passage  of  a  sound. 

Eisendrath  gives  the  order  of  frequency  of  involvement  of  the 
joints  in  eight  hundred  and  fifty-five  cases  of  gonorrheal  joints,  as 
follows:  In  the  knee,  in  158  cases;  in  the  ankle,  in  125  cases; 
in  the  wrist,  in  76  cases ;  in  the  elbow,  in  53  cases ;  in  the  shoulder, 
in  44  cases ;  in  the  hip,  in  42  cases ;  in  the  temporo-maxillary,  in 
16  cases;  in  the  small  joints  of  the  foot,  in  46  cases;  in  the  heel 
and  toes,  in  21  cases;  in  the  small  joints  of  the  hands,  in  50  cases, 
and  in  other  articulations,  in  24  cases. 

Diagnosis  of  Inflammatory  Joint  Pains. — Septic. — All  in- 
flammations of  a  joint  are  not  septic.  The  presence  or  absence  of 
infection  may  be  denoted  by  the  temperature  of  the  patient. 
Fever,  as  a  rule,  is  an  indication  of  infection.  Where  infection  is 
present,  either  rheumatic  or  septic,  the  original  site  of  entrance 
should  be  sought.  In  rheumatism  it  frequently  is  the  tonsils;  in 
gonorrhea,  the  urethra ;  in  sepsis,  the  endometrium.  Less  fre- 
quently the  infection  may  originate  from  typhoid  fever,  menin- 
gitis, and  pneumonia. 

If  the  inflammation  of  the  joint  is  non-septic  and  fever  is 
absent,  the  metabolic  and  eliminating  organs  of  the  body  should 
be  examined.  Pain  and  redness  of  a  joint  are  very  common  in 
lead  poisoning,  joint  disorders  accompanying  psoriasis  and  in  the 
so-called  uric  acid  diathesis,  the  sodium  urate  deposits  in  the  joint 
causing  pain.  In  children  scurvy  is  a  frequent  cause  of  joint 
disturbance.  In  a  suspected  case  of  rickets  the  gums  should  be 
examined  for  sponginess,  aaid  the  body  for  the  hemorrhagic  skin 
eruptions  which  are  so  characteristic  of  this  disease. 

In  rheumatic  inflammation  the  pain  is  most  severe,  and  is 
accompanied  by  an  excessive  degree  of  joint  swelling.  If  cardiac 
involvement  is  also  present,  and  a  rapid  amelioration  takes  place 
under  the  use  of  salicylates,  the  diag-nosis  is  rendered  certain. 
Should  redness  be  absent  and  temperature  little  marked,  tuber- 
culosis may  be  present.  Tuberculosis  of  a  joint  (especially  of  the 
knee)  is  frequently  present  without  redness,  and  in  many  casei? 


240 


BONE    PAINS— THE    OSTALGIAS 


without  pain.      A   tuberculin   reaction   or   tuberculous  foci  else- 
where in  the  body  would  aid  in  clearing  the  diagnosis. 

Acute  synovitis  is  characterized  by  chills,  swelling,  tenderness, 
loss  of  motion  and  redness  of  the  overlying  skin.  Stiffness  is  a 
frequent  sequela  of  synovitis.  When  it  occurs,  pain  on  motion  is 
excessive.  Stiffness  with  pain  may  also  be  the  result  of  immobi- 
lization for  long  periods. 

I  L 


PECTONEUS 


ADD.  MAG. 
ADD.  BREV. 
BR. KNEE. 

ADD  MAG. 


HIP  JOIN! 


Fig.  60. — Obturator  and  Accessory  Obturator. 
This  shows  the  relation  of  different  thigh  muscles  to  the  hip  joint. 


Hip  Joint.^ — In  diseases  of  the  hip  joint,  we  have  occasion 
to  observe  many  different  forms  of  pain,  the  varieties  of  which 
doubtless  depend  upon  the  peculiar  relationship  of  the  nerves  to 
the  joint.     The  nerves  of  the  hip  joint  are  mostly  derived  from 

^  By  Dr.  Werndorf ,  Assistant  to  Professor  Lorenz,  in  Vienna. 


JOINT    PAINS— ARTHRALGIA  241 

the  lumbar  plexus.  They  are:  (1)  a  median  skin  branch  from 
the  femoral  nerve,  and  (2)  the  obturator  nerve,  which  through 
its  posterior  branch  supplies  the  anterior  and  median  parts  of  the 
capsule,  and  through  other  branches  supplies  the  intraarticular 
ligament  and  the  acetabulum.  Many  other  nerves  reach  the  hip 
joint,  either  by  way  of  the  nervus  ischiaticus  or  the  quadratus 
femoris  from  the  sacral  plexus. 

Radiating  Pains. — The  pains  observed  in  the  hip  joint  are, 
for  the  most  part,  either  radiating  or  local.  Radiating  pains  are 
observed  in  the  early  stages  of  all  classes  of  hip-joint  disease. 
They  are  frequently  the  first  signs  of  the  so-called  voluntary  lame- 
ness, and  are  also  an  early  symptom  of  beginning  tuberculous  dis- 
ease of  the  hip.  They  are  also  observed  in  acute  and  chronic  in- 
flammations of  the  hip  joint,  and  in  growing  joints.  The  most 
frequent  point  of  radiation  is  the  knee.  It  is  very  probable  that 
the  pains  propagated  to  the  knee  arise  through  suffusion  into  the 
obturator  nerve,  which  runs  in  the  immediate  neighborhood  of  the 
joint.  Indeed,  the  pathology  of  the  hip  joint  offers  an  important 
point  for  this  sort  of  explanation  of  the  so-called  knee  pains,  for 
anatomical  examinations  show  that  the  synovial  form  (most  fre- 
quent) starts  with  proliferating  tuberculous  granulation  tissue  in 
the  acetabular  fossa,  and  also  in  the  part  of  the  joint  cavity  occu- 
pied by  the  intraarticular  ligament.  A  branch  of  the  obturator 
nerve,  supplying  the  joint,  accompanies  the  ligament  and  enters 
the  joint  through  the  incisura  aeetabuli.  Branches  from  this 
nerve  also  supply  the  upper  half  of  the  knee  joint,  and  the  median 
side  of  the  thigh,  in  which  locations  the  referred  pain  is  most  fre- 
quent. Radiating  pains  are  frequently  also  felt  in  the  lower  half 
of  the  knee  joint,  or  in  the  popliteal  space. 

Functional,  Pains. — Another  variety  of  pains  observed  in 
the  hip  joint,  which  are  of  great  interest,  are  the  functional  pains 
resulting  from  movement  and  weight  bearing.  The  principal 
difference  between  these  two  forms  of  pain  has  generally  been 
overlooked.  Lorenz  was  the  first  to  show,  on  the  foundation  of  his 
interference  therapy,  the  fundamental  differences  between  the 
movement   and   the  weight-bearing  pains.      The   so-called  move- 


242  BONE   PAINS— THE    OSTALGIAS 

ment  pains  arise  on  movement  of  the  head  of  the  bone  in  the  artic- 
ular cavity;  the  weight-bearing  pains,  on  the  contrary,  arise 
through  the  (functional)  weight-bearing  stress  on  the  bones  con- 
stituting the  joint. 

Movement  Pains. — If  a  synovial  diseased  joint  is  opened,  the 
synovial  membrane  is  found  to  be  considerably  swollen,  it  being 
three  or  four  times  thicker  than  normal,  and,  at  the  same  time, 
reddened  and  infiltrated.  The  cartilage  of  the  head  of  the  bone 
may  be  perfectly  normal.  Its  shining  whiteness  is  in  striking 
contrast  to  the  redness  of  the  synovia.  Now,  by  the  least  move- 
ment of  the  head  of  the  femur  in  the  acetabular  cavity,  the  dis- 
eased, and  therefore  very  sensitive,  synovial  membrane  is  pinched 
and  squeezed  into  folds.  It  soon  becomes  injured,  and  this  trau- 
matism chiefly  affects  the  numerous  and  multiple  divisions  of  the 
nerves  running  in  the  synovia.  Therefore  the  pain  felt  on  move- 
ment occurs  through  the  irritation  of  the  intraarticular  nerves  of 
the  synovial  membrane.  It  is  understood,  without  further  ex- 
planation, that  in  this  stage  of  the  disease  weight-bearing,  that  is, 
the  pressing  of  the  head  of  the  bone  against  the  articular  cavity, 
is  without  pain.  Therefore,  on  examination,  very  often  the  re- 
markable symptom  occurs  that  a  child  with  coxitis  walks  entirely 
free  from  pain,  and  that,  on  examination  of  a  joint  previously 
painful  on  to  and  fro  motion,  the  weight-bearing  test  proves  en- 
tirely negative.  A  light  blow  on  the  sole  of  the  foot  of  the  diseased 
and  outstretched  limb  produces  no  pain,  while  the  least  attempt  at 
movement  of  the  thigh  against  the  pelvis  produces  the  most  severe 
pain.  The  irritation  (on  movement)  of  the  intraarticular  nerves 
produces  a  reflex  spasm  of  the  muscles  which  surround  the  hip 
joint.  The  joint  is  at  once,  when  fixed  through  the  resulting 
muscular  action,  rendered  free  of  pain,  since  the  injury  of  the 
sensitive,  internal  covering  of  the  joint  is  prevented.  So  it  hap- 
pens that  a  muscular  fixed  joint  is  insensitive  against  weight  bear- 
ing, while  for  the  same  reason  night  cries  are  a  constant  symptom 
in  the  history  of  a  coxitis  patient.  In  sleep  the  muscular  spasm 
which  fixes  the  hip  joint  relaxes,  and  with  it  the  fixation  of  the 
synovial  membrane  disappears  and  any  involuntary  movement  of 


JOINT    PAINS— ARTHRALGIA  243 

the  patient  produces  the  greatest  pain.  He  is  aroused  from  sleep 
by  the  pains.  The  muscular  spasms  recur,  and  again  protect  the 
joint  from  painful  movement,  so  that  the  patient  again  falls  to 
sleep. 

Should  any  doubt  remain  as  to  the  truth  of  this  explanation  of 
the  causation  of  these  pains,  it  will  disappear  on  viewing  the 
results  of  treatment  by  early  fixation  by  means  of  a  plaster  cast. 

The  plaster  cast  takes  the  role  of  the  fixating  muscles,  and 
the  joint  will  remain  insensitive  to  weight  bearing,  so  insensitive 
that  the  coxitis  patient  is  able  to  walk  on  his  diseased  limb,  and 
frequently  can  even  jump  on  it  without  producing  pain. 

Weiglit-hearing  Pains. — The  pains  observed  on  allowing  the 
hip  joint  to  bear  weight  are  of  an  entirely  different  kind.  They 
are  mostly  local,  are  seldom  radiating,  and  disappear  if  the  patient 
rests  in  bed.  Movement  of  the  thigh  of  the  diseased  side  against 
the  fixed  pelvis  produces  no  noticeable  increase  of  the  pains.  They 
arise  through  traumatism  of  the  ligaments  and  muscles,  as  the 
result  of  a  changed  direction  of  weight-bearing.  Therefore,  they 
are  almost  always  observed  when  adduction  and  flexion  contrac- 
tions are  present  in  the  hip.  When,  as  may  frequently  be  observed, 
a  genu  valgum,  or  recuiwatum  occurs  in  addition  to  the  adduction 
flexion  contraction,  weight-bearing  pains  are  present  in  the  knee 
joint.  They  are  similar  to  the  pains  arising  from  static  deformi- 
ties, and  can  be  well  differentiated  from  the  radiating  pains  pre- 
viously mentioned.  Trauma  of  the  soft  parts  of  the  joint  is  caused 
by  the  stretching  of  the  muscles  and  tendons  on  the  adduction  side 
of  the  joint.  The  bony  structural  inhibition  itself  produces  very 
little  pain,  except  when  destruction  of  the  joint  itself  is  present. 

Physiological  investigation  (Dubois  Raymond)  has  shown  that 
equilibrium  in  walking  and  standing  occurs  not  so  much  through 
the  action  of  the  bony  elements  of  the  joint  as  through  the  play  of 
musculature  related  to  the  joint  and  the  tension  of  the  ligaments. 
The  knowledge  of  these  facts  is  of  the  greatest  value  in  the  treat- 
ment of  a  tuberculous  hip  joint,  for  it  shows  us  that  a  hip  joint, 
once  fixed  and  therefore  protected  against  joint  movement,  may  be 
subjected  to  weight  bearing.     The  functional  irritation  (friction) 


244  BONE   PAIN'S— THE   OSTALGIAS 

of  the  weight-bearing  is  suitable  to  stimulate  the  end  of  the  bone  to 
grow,  and  in  this  way  to  produce  an  ankylosis  of  the  hip  joint, 
which  is  the  object  sought. 

Tension  Pain  of  Intraarticular  Hip-joint  Abscess Besides 

movement  and  weight-bearing  j^ains,  we  recognize  in  the  hip  joint 
an  especial  form  of  pain  which  has  been  observed  exclusively  in 
intraarticular  abscess  of  this  joint.  It  is  classified  as  tension  pain, 
and  is  produced  through  the  progressive  hypertension  of  the  joint 
capsule,  due  to  an  increase  in  the  intraarticular  pressure.  The 
pain,  for  this  reason,  may  be  almost  unbearable.  The  weight- 
bearing  pains  are  felt  especially  on  walking,  and  the  movement 
pains  are  elicited  on  gross  movements  of  the  joint;  and  while  in 
both  many  intervals  of  rest  are  granted  to  the  patient,  the  pain 
of  intraarticular  abscess  is  continuous.  Pressure  of  the  bed 
clothes  alone  often  causes  intolerable  pain;  and,  as  a  rule,  a 
child  with  an  intraarticular  abscess  cries  and  screams  incessantly. 
The  tension  pains  of  an  intraarticular  abscess  defy  every  form  of 
mechanical  treatment,  and  it  is  precisely  this  negative  result  of 
an  otherwise  efficient  therapy  which  gives  very  frequently  an  im- 
portant point  for  the  diagnosis  of  an  intraarticular  abscess.  How- 
ever^ the  greatest  difficulty  underlies  the  diagnosis,  especially  of 
a  beginning  intraarticular  abscess.  One  is  unable  to  determine 
the  presence  of  fluid  in  the  joint,  owing  to  the  cavity  of  the  hip 
joint  being  \'ery  slight,  and  because  the  thick,  muscular  infundib- 
uhim  surrounding  the  joint  makes  it  inaccessible  to  the  sense  of 
touch.  Fluctuation  is  felt  only  after  the  abscess  has  penetrated 
the  capsule  and  has  become  extraarticular. 

The  diagnosis,  however,  can  be  made  by  close  attention.  A 
coxitis  patient  who  has  been  treated  a  short  time  with  mechanical 
treatment,  that  is,  with  the  plaster  trousers  or  the  so-called  com- 
bined  bandage  (Lorenz  plaster  hose  with  leg  apparatus),  may  re- 
main for  a  short  time  without  pain.  He  then  commences  to  cry 
out  a  couple  of  times  in  the  night,  but  by  day  he  is  usually  free 
of  pain.  In  a  few  days  painful  attacks  occur  also  in  the  daytime ; 
the  night  cries  become  more  frequent,  and  in  a  short  time  the 
pains  are  continuous,  so  that  the  patient  presents  a  picture  of 


JOINT    PAINS— ARTHRALGIA  245 

the  greatest  distress.  In  sj^ite  of  all  the  bandages,  the  pains 
increase,  and  evening  fever  sets  in.  This  condition  per- 
sists many  weeks  with  a  constantly  increasing  severity,  nntil 
suddenly,  over  night,  the  pains  entirely  cease,  and  the  very 
sick  patient  ajDpears  again  as  thongh  given  back  to  life.  The 
intraarticular  abscess  has  broken  through  and  has  become 
extraarticular,  and  will,  finally,  be  palpable  as  a  subcutaneous 
abscess. 

A  little  trick,  which  is  suitable  to  establish  objectively  a 
beginning  intraarticular  abscess,  may  be  brought  into  play.  With 
the  patient  in  an  abdominal  posture,  normally,  the  medium-size 
trochanter  can  be  touched  in  a  small  depression  corresponding  to 
the  retrochanteric  fossa.  This  part  of  the  posterior  and  upper  sur- 
face of  the  neck  and  of  the  femur  is  not  normally  inclosed  by  the 
joint  capsule,  but  in  the  early  stages  of  an  intraarticular  collection 
of  fluid,  the  dilated  capsule  is  swollen  and  covers  the  otherwise 
free  and  extraarticular  part  of  the  posterior  part  of  the  neck  of 
the  femur,  so  that,  by  close  investigation,  a  circumscribed  fluctua- 
tion may  at  this  point  be  determined. 

The  knowledge  of  the  beginning  of  an  intraarticular  abscess 
is,  therefore,  of  a  significance  not  to  be  depreciated,  because  in  a 
positive  diagnosis  the  early  opening  of  the  joint  (arthrotomy)  re- 
lieves the  patient  with  one  stroke  from  all  his  suffering. 

According  to  William  Bruce  (Scottish  Med.  and  Surg.  Jour., 
1904,  XIV,  297-304),  gouty  de^josits  may  occur  in  the  hip  joint. 
These,  he  claims,  irritate  the  articular  (nerve)  branch  which, 
arising  from  the  fourth,  fifth  L.  and  first  S.  segments,  causes  irri- 
tation to  these  segments,  and  gives  rise  to  pain,  referred  to  the 
areas  of  distribution  of  the  sensory  nerves  derived  from  them. 
These  areas  of  distribution  almost  coincide  with  the  area  of  distri- 
bution of  the  pain  in  cases  of  sciatica.  He  differentiates  the  gouty 
joint  from  sciatica,  however,  in  that,  in  this  condition:  (1)  There 
is  a  wasting  of  the  gluteal  muscles.  This  is  absent  in  sciatica,  be- 
cause these  muscles  are  not  supplied  by  the  sciatic  nerve.  (2)  In  a 
gouty  hip  joint  there  will  also  be  noted  impairment  of  motion — 
also    (very  frequently)    a  grating  and  roughness  on  movement. 


246  BONE   PAINS— THE   OSTALGIAS 

(3)  There  is  also  lameness  of  the  hip  and  (4)  tenderness  to  pres- 
sure over  the  hip  joint.  Both  of  these  are  absent  in  sciatica. 
These  considerations  also  hold  true  for  an  arthritis  deformans  of 
the  hip.  In  all  cases,  however,  an  X-ray  picture  should  be  taken, 
and  the  diagnosis  made  certain 


CHAPTER  XII 

THE  CIRCULATORY  SYSTEM 

The  circulatory  system  consists  of  the  heart,  the  arteries, 
capillaries,  aud  the  veins.  The  heart  is  considered  under  its  ap- 
propriate heading  (q.  v.).  At  the  present  time  we  shall  consider 
the  blood  vessels  (arteries  and  veins).  The  capillaries  can  hardly 
be  said  to  cause  pain,  except  possibly  in  inflammatory  states,  where 
undoubtedly  they  have  a  slight  influence  in  giving  rise  to  the 
throbbing  pain  felt  in  those  conditions. 

PAIN    CAUSED    BY   CHANGES    IN    THE   BLOOD    SUPPLY 

In  circulatory  disturbances,  pain  is  produced  either  by  a  too 
great  (disproportionate)  increase  or  decrease  in  the  blood  supply. 
When  the  blood  is  increased  in  quantity,  congestion  results,  and 
pressure  is  made  upon  the  terminal  nerve  filaments.  This  conges- 
tion is  of  two  varieties,  namely,  active  and  passive.  The  active 
variety  has  been  considered  under  inflammatory  pain.  The  passive 
/ariety  (passive  congestion)  we  will  now  consider. 

Pains  from  Increase  in  Blood  Supply. — First  of  all,  what  is 
meant  by  passive  congestion  ?  By  this,  we  here  understand  a  con- 
dition in  which  there  is  an  excess  of  blood  in  a  part,  due  to  back- 
ward pressure.  This  pressure  can  never  become  excessive ;  so  that 
the  most  to  be  expected  in  this  condition  is  pain  of  a  dull,  aching 
character.  This  pain  is  always  felt  directly  in  the  congested  area 
or  is  referred  to  the  skin  region  associated  with  the  congested 
organ.  In  static  congestion  a  part  of  the  pain  undoubtedly  is  due 
also  to  toxic  products,  which  must,  of  necessity,  accumulate  in  the 
tissue  when  the  exit  from  the  affected  part  is  obstructed.  Such 
stasis  pains  are  produced  in  the  liver  and  spleen  when  the  right 

247 


248  THE    CIRCULATORY    SYSTEM 

heart  circulation  fails.  These  are  probably  the  two  best  examples 
of  this  condition,  because  in  both  cases  inflammation  can  be  abso- 
lutely excluded.  The  cause  of  the  pain  is  the  stretching  of  the 
capsule  of  these  organs,  with  possibly,  at  the  same  time,  some  pull 
and  drag  on  the  ligaments.  Of  course,  as  a  cause  of  passive  ob- 
struction, tumors  or  displaced  organs  pressing  upon  the  returning 
veins  must  not  be  forgotten. 

Pains  from  Diminution  in  Blood  Supply.  — A  diminution  of 
the  blood  supply  to  a  part  causes  pain  by  the  starvation  of  the 
tissues  which  results ;  and,  as  tlie  nervous  tissues  are  by  far  the 
most  sensitive,  disturbance  in  them  is  first  produced,  and  sudden, 
sharp  jDain  is  produced.  This  is  well  illustrated  in  Raynaud's 
DISEASE,  the  symptoms  of  which  are  due  to  a  contraction  of  the 
smaller  arterioles  in  an  extremity  (generally  the  hand).  In  this 
disease  sudden,  sharp  pain  occurs  in  an  extremity,  increasing  with 
the  elevation  of  the  part.  The  surface  is  cool  and  white,  and  sen- 
sation is  diminished,  the  part  being  numb  to  the  touch.  This 
symjjtom  complex  appears  (and  disappears)  at  irregular  intervals, 
until  finally  a  small,  atrophic  ulcer  develops  on  the  most  distal 
part  of  the  limb  affected.  This  may  progress  upward,  or  a  portion 
of  a  finger  or  toe  may  become  gangTenous.  In  other  cases  the  j^ri- 
mary  contraction  is  followed  by  a  dilatation  of  the  vessels,  and  the 
part  becomes  swollen  and  purple  (Sachs,  022).  In  these  cases, 
when  the  limb  is  elevated,  the  pain,  which  is  of  a  drawing,  burn- 
ing type,  disappears.  Raynaud's  disease — which  is,  after  all,  a 
fairly  ample  syndrome — is  in  reality  a  dual  affair.  The  cells  in 
the  spinal  cord,  usually  termed  sympathetic  and  trophic,  and  regu- 
lating the  vessels,  are  those  primarily  affected.  The  pains  are 
largely  due  to  imi^lication  of  this  system  of  nerves,  and  are 
grouped  by  Head  with  the  general  group  of  protopathic  and  deep 
sensibility  pains.  Buerger  has  recently  described  a  state  in  which 
the  arteries  of  the  lower  limbs  become  thrombosed  or  obliterated 
(endarteritis  obliterans.  See  intermittent  claudication.).  Here  the 
pain  is  most  intense  and  is  constant  while  the  limb  is  dependent, 
but  disappears  on  the  elevation  of  the  limb.  No  medicinal  treat- 
ment can  alleviate  the  pain  of  the  unfortunate  sufferer,  and  the  only 


ARTERIAL    DISEASES    CAUSING    PAIN  249 

means  of  easing  his  agony  is  high  amputation  of  the  diseased  limb. 
This  condition  has  been  called  thrombo-endarteritis  obliterans. 

In  PUKPUKA  H.EMORKHAGicA  the  pain  is  also  caused  by  obstruc- 
tion to  the  onward  circulation.  The  cause  can  be  explained  more 
explicitly  if  we  examine  the  cause  of  the  hemorrhage  in  a  case  of 
purpura  hsemorrhagica  due  to  syphilis  (reported  by  Sabrazes  and 
Duperin,  573).  In  this  case  the  hemorrhages  were  due  to  the 
rupture  of  capillaries,  due  to  mechanical  obstruction  by  the  intes- 
tinal granulomatous  lesions  of  the  disease.  These  lesions  will  ex- 
plain the  pain  felt  in  these  conditions,  for  it  is  a  noticeable  fact 
that  the  pain,  not  only  in  this,  but  in  most  rheumatic  purpuras,^  is 
very  great  until  the  hemorrhage  appears,  when  it  is  eased.  In 
other  words,  during  the  period  of  distention  of  the  vessel,  there  is 
pain,  while  on  rupture  and  removal  of  the  intraarterial  tension  the 
pain  disappears.  In  any  case,  when  an  artery  is  affected,  the  pain 
follows  the  distribution  area  of  the  affected  artery. 

FuNCTiojs^AL  ACTIVITY^  bccause  of  the  increased  demand  made 
upon  the  arterial  system,  often  causes  severe  pain  when  the  blood 
supply  to  the  active  part  is  deficient.  This  is  illustrated  in  cases 
of  aortitis,  stenosis  of  the  coronaries,  passive  congestion  of  the 
liver  and  spleen,  and  in  arteriosclerosis  of  the  mesenteric  vessels. 

ARTERIAL    DISEASES    CAUSING    PAIN 

The  principal  arterial  diseases  causing  pain  are  arteritis, 
thrombosis,  embolism  and  aneurysm.  It  has  been  claimed  by 
Granville  that  the  vasomotor  nerves  have  a  component  of  sensory 
fibers.  Should  such  be  the  case,  one  can  easily  understand  why, 
in  disturbances  of  the  vessels,  pain  should  result.  That  a  comple- 
ment of  sensory  fibers  accompany  vasomotor  nerves  may  in  part 
be  true,  for  in  performing  abdominal  operations  under  a  local 
anesthetic,  it  has  been  found  that  the  ligating  of  vessels  is  very 
painful.  Yet  it  seems  that,  in  most  cases,  especially  in  the  pres- 
ence of  inflammation  of  the  vessels,  the  pain  is  due  to  the  in- 

1 1  am  not  aware  of  any  work  done  as  yet  which  would  prove  that  the 
cause  of  obstruction  of  the  vessels  in  purpura  haemorrhagica  is  either  emboli 
or  thrombi,  but  reasoning  from  analogy  such  would  seem  to  be  the  case. 


250  THE    CIRCULATORY    SYSTEM 

flammation  which  has  extended  to  the  adjacent  nerves.  This  has 
been  set  forth  by  Buch  as  the  cause  of  pain  in  aortitis. 

Inflammation.  — When  inflammation  occurs  in  an  artery  the 
tima  is  the  part  first  affected.  Up  to  this  point  no  pain  results; 
then  the  inflammation  spreads  to  the  media,  and  finally  to  the  ad- 
ventitia,  in  which  it  seems  that  the  receptors  for  pain  sensibility 
may  lie.  The  arteries  of  smaller  caliber  are  not  as  sensitive  as  the 
larger  ones.  Perhaps  the  best  place  to  study  arterial  changes  and 
the  sensory  results  is  in  the  aorta.  Here  the  inflammation,  as  long 
as  it  remains  in  the  aorta,  produces  no  pain,  but  it  soon  passes  out 
and  involves  the  neighboring  cords  of  the  sympathetic.  Ordinarily 
the  sympathetic  is  not  painful,  but,  according  to  Buch  (171), 
Wutzler,  Flourens,  Bruchet,  Valentin,  and  Longet  have  found 
that  the  sympathetic  becomes  sensitive  through  inflammation  or 
congestion.  Confirmation  of  the  fact  that  inflammation  may  be 
communicated  to  the  sympathetic  from  an  aortitis  can  be  found  in 
the  writings  of  Debove  and  Letulle  (38-1),  Kigal  and  Juhel-Rinon 
(385),  Weber  (386),  Lanceraux  (387),  Dutil  and  Lanny  (388), 
Lapinsky  (389),  Duplaix  (390),  and  Holsti  (391),  who  have 
found  that  inflammation  of  the  aorta  was  communicated  through 
the  adventitial  coat  to  the  aortic  and  celiac  plexus.  Buch  agrees 
with  these  observers,  and  discredits  the  view  of  Potain  (380)  that 
the  pain  is  due  to  inflammation  of  the  arterial  wall.  Engleman 
(381),  like  the  previous  observers,  believes  that  the  pain  is  due  to 
hyperalgia  of  the  aortic  plexus.  Buch  (p.  291),  in  affirming  these 
views,  claims  that  he  not  only  has  found  the  aorta  hyperalgesic, 
but  also  the  two  bordering  sympathetic  cords,  or  at  least  one  of 
them. 

The  pain  of  aortitis  is  sudden  in  onset,  occurs  in  the  epigas- 
trium, and  resembles  angina  pectoris  in  its  severity  and  sudden- 
ness. It  is  produced  by  exertion  and  by  the  ingestion  of  food,  the 
kind  seeming  not  to  be  so  important  as  the  quantity.  The  pain 
comes  on  in  paroxysms,  each  individual  paroxysm  lasting  only  a 
few  minutes.  Paroxysms  seem  to  be  especially  produced  by  eleva- 
tion of  the  arterial  pressure,  particularly  when  it  is  accompanied 
by  contraction  of  the  superficial  vessels.     A  cause  of  this  contrac- 


ARTERIAL    DISEASES    CAUSING    PAIN  251 

tion  may  be  excessive  functioning  of  the  suprarenals  (Bucb).  In 
this  relation  it  seems  that  when  the  blood  is  thrown  into  the  deeper 
vessels  because  of  their  stiffness  they  are  unable  to  dilate  and 
accommodate  it.  As  a  consequence,  congestion  of  the  sympathetic 
occurs.  This  gives  rise  to  pain,  because  of  its  previous  irritability. 
A  reflex  dilatation  of  the  vessels  then  takes  place,  change  of  the 
blood  flow  occurs,  and  the  congestion  and  pain  are  relieved.  It  is 
characteristic  of  these  cases  that  the  pain  is  relieved  by  strophan- 
thus  or  dinretin. 

The  time  of  onset  is  variable,  and  often  seems  to  be  the  result 
of  exertion.  Yet.  exertion  is  not  the  cause  in  all  cases,  for,  in  some 
instances,  the  i^ain  appears  in  the  middle  of  the  night  while  the 
patient  is  sleeping  quietly.  The  position  of  the  body  of  the  patient 
seems  to  make  a  difference  only  in  an  individual  case.  With  some, 
the  pain  comes  on  when  they  are  standing,  while  with  others  it 
appears  when  they  are  lying  down  (Brunton,  11).  Kreuzfuchs 
(572)  claims  that  the  pain  is  most  liable  to  develop  when  the 
patient  is  lying  down.  Brunton  calls  attention  to  the  distention  of 
the  bowel  with  flatus,  which  frequently  comes  on  some  time 
during  the  attack.  During  the  attack  tenderness  of  the  aorta  and 
neighboring  nerve  trunks  is  present,  and,  according  to  Brooks  (93, 
p.  784),  persists  for  some  time  afterward. 

In  some  cases,  as  related  by  Eossback  (623),  symptoms  of 
gastric  disturbances  may  be  present  for  years  without  a  typical 
attack.  These  are  the  eases  which  are  frequently  diagnosed  as 
stomach  disorders.  Arteriosclerosis  of  the  aorta  seems  to  be  more 
common  in  men  than  in  women,  and  most  frequent  in  the  years 
from  forty  to  fifty. 

Increase  of  Blood  Pressure.  ^ — That  increase  of  blood  pressure 
alone  may  cause  pain  is  afiirmed  by  Pal  (67-1),  who,  in  examining 
cases  of  lead  colic,  found  the  blood  pressure  in  the  intestinal  ves- 
sels increased  from  one-half  to  twice  the  normal  pressure.  This 
increased  pressure  irritates  the  terminal  nerve  filaments,  or  re- 
duces the  circulation  in  the  intestine,  thus  causing  pain. 

Intermittent  Claudication. — There  is  a  peculiar  and  compara- 
tively   rare    condition,    especially    frequent    in    male    Russian 


252  THE    CIRCULATORY    SYSTEM 

Hebrews,  in  Avbicli  pain  in  the  lower  limbs  is  associated  with  vas- 
cular alterations.  It  was  first  described  by  Charcot.  There  is,  in 
this  disorder,  a  sensation  of  numbness,  fatigue  and  pain,  which 
comes  on  in  one  or  both  legs  on  walking.  It  increases  in  severity 
after  a  short  time — fifteen  minutes  to  half  an  hour — and  renders 
locomotion  impossible.  On  resting,  the  pain  disappears,  to  ap- 
pear again  after  walking.  In  advanced  cases  the  pains  occur 
spontaneously,  from  time  to  time,  or  they  are  persistent. 

The  pains  resemble  those  of  a  sciatica,  although  they  are  apt 
to  be  more  diffuse,  involving  the  entire  calf,  or  thigh,  rather  than 
following  a  nerve  trunk.  Cyanosis,  pallor  and  coldness  are  fre- 
quent accompanying  symptoms.  They  can  be  induced  by  having 
the  patient  walk  briskly,  when  the  sole  of  the  foot  will  be  observed 
to  be  waxy  and  cold.  The  absence  of  pulsation  in  the  dorsalis 
pedis  and  posterior  tibial  arteries  is  a  marked  feature  of  many 
cases.  Arteriosclerosis  is  a  constant  accompaniment,  and  X-ray 
examinations  of  the  legs  will  often  show  the  presence  of  hardened 
calcified  blood  vessels.  An  obliterating  arteritis  alters  the  nutri- 
tion of  the  muscles  and  may  be  the  cause  of  the  pain  on  walking. 

At  times  a  spastic  vascular  condition  may  rest  at  the  bottom  of 
the  disorder  without  any  pronounced  organic  vascular  lesions, 
although  these  are  probably  early  cases.  It  may  also  be  due 
to  congenitally  small  blood  vessels.  In  the  majority  of  these  cases 
the  organic  vascular  changes  come  along  later. 

An  intermittent  claudication  of  the  arm  may  be  present. 

Erythromelalgia.  — Here  the  chief  features  are  pain  and  red- 
ness of  the  skin,  particularly  of  the  feet,  less  often  of  the  hands, 
still  more  rarely  of  all  four  extremities.  Pain  is  an  early  sign.  It 
comes  on  after  over-exertion,  and  is  usually  abrupt  in  onset,  al- 
though occasionally  gradual  in  its  development.  The  balls  of  the 
toes  and  the  heels  are  the  sites  of  maximum  involvement.  Rarely 
the  whole  extremity,  upper  or  lower,  is  invaded.  There  is,  in  addi- 
tion to  the  pain,  redness,  and  the  tips  of  the  fingers  or  toes  are 
swollen.  There  is  a  sensation  of  exquisite  pain,  with  burning, 
and,  as  a  matter  of  fact,  the  local  temperature  is  raised.  The 
blood  vessels  pulsate,  small  nodules  appear,  and  marked  sweating 


AETERIAL    DISEASES    CAUSING    PAIN  253 

is  apparent.     Other  sensory  changes  are  slight,  and  consist  of  a 
mild  hyperesthesia  or  hypesthesia. 

The  pain  varies.  In  the  more  advanced  cases  it  is  severe  tor- 
ture, but  may  vary  from  a  mild  discomfort  to  agonizing  pain. 
Cold  and  the  recumbent  posture  relieve  it,  while  lowering  the  af- 
fected part,  standing  or  walking  (if  the  feet  are  affected),  or  the 
application  of  heat,  increase  its  severity.  On  walking  (feet  be- 
ing affected),  the  swelling  is  increased,  and  the  redness  becomes 
successively  more  marked. 

This  condition  is  probably  more  than  a  single  entity,  since  it 
may  be  associated  with  disease  of  the  sympathetic  cells  (in  the 
cord),  or  with  disease  of  the  peripheral  nerves.  Again  it  is  allied 
with  vascular  disorders.  It  is  probably  a  vasomotor  neurosis  of 
central  origin. 

Embolism  and  Thrombosis  of  the  Mesenteric  Arteries. — The 
mesenteric  arteries  merit  separate  consideration ;  and  it  is  espe- 
cially necessary  to  review  the  two  most  important  causes  of  pain 
in  lesions  of  these  vessels,  namely,  thrombosis  and  embolism. 

In  both  of  these  conditions  the  blood  supply  to  the  intestine  is 
cut  off  and  paralysis  (absence  of  peristalsis)  occurs  in  the  affected 
segment  of  the  bowel.  This  paralyzed  bowel  acts  as  a  barrier  to 
the  forward  movement  of  the  feces,  and  all  the  sigiis  and  symptoms 
of  obstruction  take  place.  In  embolism  these  symptoms  are,  as  a 
rule,  sudden  in  onset,  while  in  thrombosis  they  develop  more 
slowly.  As  in  intestinal  obstruction  from  other  causes,  generally 
the  first  sign  of  the  disease  is  pain,  which  is  sudden,  sharp,  acute, 
and  is  referred  to  the  epigastrium,  if  the  superior  mesenteric  ar- 
tery is  affected,  while  if  the  inferior  is  the  one  involved,  the  pain 
is  referred  to  the  region  of  the  abdomen,  below  the  umbilicus. 
Shock  is  a  constant  symptom,  accompanying  the  pain.  After  the 
first  acute  pain,  there  is  often  a  lulling  of  the  pain-sensation,  but 
the  pulse  continues  rapid  (the  effect  of  the  shock).  In  a  short  time 
the  pain  again  becomes  prominent,  and  is  of  a  colicky  character. 
The  primary  pain  is  regarded  as  due  to  the  sudden  shock  to  the 
mesenteric  nerves,  the  secondary  as  due  to  the  pull  and  drag  upon 
the  mesentery.     As  soon  as  the  segmental  bowel  paralysis  becomes 


254  THE    CIRCULATORY    SYSTEM 

complete,  signs  of  obstruction,  such  as  vomiting,  intervene.  The 
vomitus  consists,  at  first,  of  the  contents  of  the  stomach ;  later, 
of  the  bowel  down  to  the  point  where  the  obstruction  has  occurred. 
The  bowel  movements  at  this  time  often  contain  blood,  which  is 
bright  scarlet  and  somewhat  fluid,  in  obstruction  of  the  inferior 
mesenteric.  It  is  dark  in  color  and  somewhat  clotted  in  lesions  of 
the  superior  mesenteric  artery.  A  tumor  composed  of  gas  also 
makes  its  appearance  in  the  abdomen.  This  tumor  is  generally 
more  marked  on  the  left  side  in  lesions  of  the  superior  mesenteric, 
while  in  lesions  of  the  inferior  mesenteric  it  is  more  marked  on 
the  right  side  and  across  the  abdomen.  This  tumor  mass  quickly 
becomes  of  great  extent,  and  soon  occupies  the  entire  abdomen.  At 
the  same  time  a  transudation  takes  place,  and  on  celiotomy  a 
bloody  peritoneal  fluid  is  found.  Should  the  obstruction  be  more 
gradual,  such  as  occurs  from  an  arteriosclerosis,  pain  is  a  marked 
symptom.  It  is  not  constant,  but  is  of  a  flitting  character,  such 
as  we  find  present  in  another  location  in  angina  pectoris.  Pain 
of  this  character,  without  any  well-defined,  apparent  pathology, 
should  always  cause  us  to  examine  the  arterial  system  for  arterio- 
sclerosis. 

Aneurysm. — When  the  coats  of  an  artery  are  abnormally  di- 
lated, singly  or  en  inasse,  we  have  a  condition  called  aneurysm.  In 
this  the  pain  is  constant  and  gnawing  as  a  rule.  In  some  cases  it 
is  paroxysmal,  though  often  in  the  early  stages  of  aneurysm  it  may 
be  entirely  absent.  In  many  cases  the  patient  localizes  the  pain 
over  the  tumor  mass  by  pressing  over  the  affected  area  with  his 
hand;  and  a  characteristic  of  the  disease  is  that  deep  pressure  is 
always  very  grateful.  Should  any  sensory  nerves  be  pressed  upon 
by  the  tumor  mass,  pain  is  referred  to  their  peripheral  distribu- 
tions. These  referred  pains  vary  with  the  situation  of  the  tumor. 
When  the  arch  of  the  aorta  is  involved,  the  local  pain  is  felt  to  the 
right  of  the  sternum  at  about  the  junction  of  the  second  or  third 
rib  with  the  sternum,  and  the  referred  pain  is  felt  in  the  inner  side 
of  the  right  arm,  and  extends  as  far  down  as  the  elbow.  Fre- 
quently in  an  aneurysm  of  the  thoracic  aorta  the  pain  does  not 
follow  the  distribution  of  the  intercostal  nerves,  but  is  located  over 


DISEASES    OF    THE    VEINS    CAUSING    PAIN  255 

the  back  in  the  distribution  area  of  the  spinal  nerves.  It  may  also 
radiate  into  the  left  shoulder  and  arm.  The  aneurysms  of  the 
thoracic  aorta,  however,  do  not  produce  as  much  pain  as  do  those 
of  the  abdominal  aorta.  In  this  latter  pain  is  very  severe,  and  is 
felt  in  the  back,  as  a  rule.  At  first  it  is  somewhat  paroxysmal,  and 
then  takes  on  a  dull,  boring  character.  When  this  occurs,  the  diag- 
nosis of  bony  involvement  may  be  made  with  absolute  certainty. 
Certain  positions,  namely,  those  in  which  pressure  is  made  upon 
the  vertebrae,  cause  extreme,  almost  unbearable,  pain.  Hyperal- 
gesia, corresponding  to  Head's  zones,  is  often  present.  These 
areas  of  hyperalgesia  should  be  carefully  sought  for  and  mapped 
out.  In  all  cases  of  suspected  aneurysm  careful  inquiry  should  be 
made  as  to  the  presence  of  pain,  because  the  patient  frequently 
neglects  to  mention  it. 

DISEASES  OF   THE  VEINS  CAUSING  PAIN 

The  lesions  of  the  veins  causing  pain  are  inflammation,  throm- 
bosis and  varices. 

Inflammation  of  the  Veins. — Inflammation  of  the  veins  (phle- 
bitis) causes  a  very  severe  pain,  which  is  more  likely  due  to  an 
associated  involvement  of  the  surrounding  tissues  than  to  the  in- 
flammation in  the  vein  itself.  Nevertheless,  irrespective  of  the 
cause,  the  pain  is  most  severe,  constant  and  aching  in  character, 
and  is  greatest  when  the  limb  is  in  the  dependent  position.  The 
pain  is  increased  by  pressure.  By  means  of  the  tenderness  on 
pressure,  the  entire  distribution  area  of  the  vein  can  be  defined. 
Phlebitis  is  very  common  in  the  femoral  distribution  following 
child-birth,  during  which  a  slight  infection  of  the  iliac  vein  has 
taken  place.  It  is  also  very  frequent  in  the  femoral  veins  follow- 
ing typhoid  fever.  When  so  affected,  the  patient  voluntarily  lies  still, 
because  the  pain  is  increased  by  the  slightest  movement.  The  con- 
dition persists  for  a  varying  period  of  time,  and  then  disappears, 
although  slight  soreness  lasts  for  some  time.  In  some  cases  of 
phlebitis,  the  i^ain  is  referred  to  distant  areas.  This  is  due  either 
to  pressure  on  an  adjacent  nerve  by  the  inflamed  vein,  or  to  a 


256  THE    CIRCULATORY    SYSTEM 

communicated  infection.  In  cases  of  pressure  or  inflammation  of 
the  sciatic,  or  of  the  lumbosacral  cord,  the  pain  is  referred  into 
the  area  of  distribution  of  the  sciatic  (Peterson,  625).  It  is  most 
intractable,  and  is  curable  only  on  the  amelioration  of  the  causa- 
tive lesion. 

Thrombosis. — Since  thrombosis  of  a  vein  is,  in  nearly  all 
cases,  nothing  more  than  an  inflammatory  process,  the  above  de- 
scription of  phlebitis  will  equally  well  apply  to  it. 

Varicose  Veins.  — Of  varicosities  it  is  only  necessary  to  speak 
of  those  of  the  lower  extremities.  Varicosities  in  other  regions 
are  entirely,  or  almost  entirely,  painless.  ^Yhen  varicosities  occur 
in  the  lower  extremities,  the  external  and  internal  saphenous  are 
the  veins  principally  affected ;  and  it  seems  that  the  internal  is,  as 
a  rule,  more  severely  involved  than  the  external.  Consequently, 
the  local  symptoms  will  be  more  marked  on  the  inner  than  on  the 
outer  side  of  the  leg.  This  agrees  well  with  the  histories,  for 
most  of  the  patients  complain  of  pain  beginning  above  the  knee 
and  running  around  to  the  inner  side  of  the  leg,  thence  down  on 
the  posterior  surface  of  the  calf,  extending,  in  some  cases,  even  as 
far  as  the  ball  of  the  foot.  Usually  the  pain  is  worse  at  night. 
During  the  day  the  patient,  as  a  rule,  has  been  standing  on  his  feet 
more  or  less,  and  a  certain  amount  of  inflammatory  congestion  re- 
sults from  this.  In  many  cases  of  varicosities  of  the  internal 
saphenous  if  pressure  be  made  on  the  anterior  crural,  pain  radiat- 
ing into  the  inner  half  of  the  thigh  and  the  leg  will  be  felt.  After 
the  formation  of  an  ulcer,  the  pains  are  very  severe,  and  make  the 
patient's  life  miserable.  They  are  eased  by  the  application  of 
firm  pressure,  which  would  seem  to  indicate  that  they  are  due 
either  to  traction  from  the  excessive  granulations,  which,  when 
filled,  drag  upon  and  stretch  the  terminal  nerve  filaments,  or  to 
exposure  of  the  nerve  endings  in  the  floor  of  the  ulcer,  which 
follows  ui^on  the  removal  of  the  ordinary  protective  layers  of  the 
skin.  In  any  case  the  pain  is  extremely  severe  and  is  much  worse 
when  the  limbs  are  in  a  dependent  position. 


CHAPTEK  XIII 

THE   GLANDULAR   TISSUES 

The  Glands.  — The  principal  glandular  structures  are  the 
glands  with  ducts,  as  the  mammary  and  those  found  in  the  ali- 
mentary tract  (salivary,  pancreas),  and  those  without  a  duct,  the 
so-called  ductless  glands,  as  the  lymphatic  glands,  the  thymus, 
thyroid,  pituitary  and  the  adrenals.  There  are  also  numerous 
small  secreting  glands  found  in  the  mucous  lining  of  the  alimen- 
tary, respiratory  and  genitourinary  systems,  but  these  are  of  such 
minor  importance  that  they  do  not  merit  a  consideration.  When 
pain  is  located  in  a  glandular  structure,  it  is  due,  as  a  rule,  to  dis- 
tention of  the  capsule  of  the  gland.  This  distention,  in  its  turn, 
is  usually  the  result  of  inflammation. 

In  those  cases  in  which  distention  has  occurred  gradually  pain 
may  be  absent.  As  a  rule,  it  is  present  only  when  the  distention  is 
acute.  The  pain  of  large,  glandular  abscesses  or  of  tumors  of  the 
glands  is  further  increased  by  the  pressure  of  the  tumor  mass 
upon  adjacent  organs  or  nerves.  In  case  of  pressure  upon  nerves, 
the  pain  is  referred,  as  a  rule,  to  the  peripheral  distribution  area 
of  the  nerve  or  nerves  involved. 

A  special  consideration  of  the  most  important  of  the  glandular 
structures  is  in  order.  We  shall  commence  with  the  mammary 
gland,  after  which  we  shall  consider  the  adrenals,  mesenteric,  thy- 
mus, and  thyroid. 

The  Mammary  Gland. — The  mammary  gland  is  situated  in 
the  lower  part  of  the  anterior  lateral  surface  of  the  thorax.  The 
sensory  receptors  of  the  gland  are  found  in  the  alveoli,  from  which 
the  fibers  collect  to  ultimately  join  the  fourth,   fifth  and  sixth 

257 


258  THE    GLANDULAR   TISSUES 

intercostals,  in  which  they  run  to  the  cord.  The  sympathetic 
associations  are  with  the  thoracic  branches.  The  skin  over  the 
gland  receives  its  nerve  supply  from:  (1)  the  supraclavicular 
branches  of  the  cervical  plexus,  and  (2)  the  anterior  and  lateral 
cutaneous  branches  of  the  second  to  the  fifth  intercostals. 

Pains  in  the  breast  may  occur  at  certain  physiological  periods 
of  a  woman's  life,  such  as  in  infancy  (shortly  after  birth),  pu- 
berty, during  menstruation,  and  at  the  beginning  of  pregnancy. 
These  pains  may  be  pure  reflex,  or  rather  transferred,  pains,  and 
are  probably  due  to  stimuli  carried  through  the  nervous  system, 
probably  by  the  same  well-defined  paths  through  which  other 
stimuli  are  carried  when,  in  pregnancy,  the  breast  begins  to  per- 
form its  function,  and  lactation  commences.  It  is  a  moot  question 
whether  there  is,  or  is  not,  objective  cause  for  this  phenomenon, 
for  it  seems  that  the  stimuli  transferred  to  the  breast  from  the 
genital  organs  cause  some  slight  tumescence  in  the  breast,  prob- 
ably enough  to  produce  a  subjective  sensation  of  pain,  but  not 
enough  to  be  perceived  objectively.  A  peculiar  thing  about  this 
pain,  which  seems  to  verify  its  nervous  genesis,  is  that  it  may  be 
spread  over  a  wide  area,  so  that  it  sometimes  involves  the  side  of 
the  thorax  and  the  arm.  This  might  be  accounted  for  by  the  over- 
flow phenomenon  which  has  been  described  in  a  previous  chapter. 
The  intensity  of  the  pain  varies  from  a  slight,  hardly  noticeable 
sensation,  to  one  of  most  intense  distress.  The  hyperalgia  is  not 
always  confined  to  one  breast,  but  may  involve  both.  In  the 
newly-born  infant,  an  inflammatory  change  sometimes  occurs  in 
the  breast.  This  is  probably  painful,  but  we  have  no  means  of 
drawing  positive  conclusions.  (See  Uterus  and  Mammary  Pain  in 
Uterine  Disease.) 

Pain  in  the  breast  may  be  due  to  the  following  pathologic 
causes : 

(1)  Inflammation:  (a)  lactation  mastitis;  (b)  stagnation 
mastitis;  (c)  pyogenic  mastitis  (extension  from  neighborino"  struc- 
tures, lymphatics,  blood)  ;  (d)  small  abscesses  which  form  m 
the  areola  from  a  fissured  nipple. 

(2)  New  growths:  (a)  malignant,  as  in  carcinoma  and  sar- 


THE   ADRENALS  259 

coma  (pain  and  tenderness  are  not  marked,  but  may  be  present 
periodically)  ;  (b)  benign,  as  fibroids. 

Tumors  of  the  breast,  as  a  rule,  do  not  give  rise  to  referred 
pain.  Fissure  of  tbe  nipple  is  very  painful,  the  same  as  is  a 
fissure  at  any  of  the  other  openings  of  the  body;  for  example, 
the  anus,  the  mouth,  or  the  urethra.  Simple  cysts  of  the  breast 
generally  give  rise  to  considerable  pain,  especially  if  they  are  of 
rapid  growth. 

Most  of  the  pain  produced  by  mammary  changes  is  local,  but 
retention  of  milk,  suckling  (forcible),  and  pulling  on  the  nipple 
often  give  rise  to  referred  pain  in  the  area  of  the  fourth  and  fifth 
dorsal  segment.  It  seems  to  be  an  invariable  rule  that  traction 
upon  the  nipple  produces  pain  over  the  angle  of  the  scapula  pos- 
teriorly. Sometimes  it  is  referred  along  the  side  to  the  anterior 
part  of  the  chest,  and  is  felt  beneath  the  breast. 

Pain  and  discomfort  during  menstrual  periods  should  cause 
the  diagnosis  to  lean  toward  mastitis.  Carcinoma  in  the  early 
stages  is  generally  not  tender,  while  mastitis,  as  a  general  rule,  is 
tender. 

The  breast  may  also  be  subject  to  referred  pain  from  the 
female  sexual  organs,  for  which  see  p.  715. 

The  Adrenals. — The  most  common,  in  fact  the  only,  condition 
in  the  adrenals  which  we  are  sure  of  as  a  cause  of  pain  is  hemor- 
rhage. The  hemorrhage  comes  on  suddenly  and  causes  a  great  dis- 
tention of  the  capsule  of  the  gland.  This,  of  course,  produces 
pain,  sudden  in  onset,  and  most  intense.  It  is,  as  a  rule,  localized 
in  the  epigastrium,  but  may  radiate  to  the  hypochondrium,  or  to 
the  lower  abdomen.  Digestive  disturbances  in  the  form  of  per- 
sistent vomiting  and  diarrhea  are  associated  with  this  pain,  while 
at  the  same  time  a  fall  of  blood  pressure,  rapid,  weak  pulse,  and 
reduction  in  temperature  occur.  The  skin  gradually  assumes  a 
yellowish  or  brownish  color.  Debility,  coma  and  death  finally 
ensue.  In  regard  to  the  debility,  Murdock  (627),  quoting  from 
Neusser,  says  that  the  "permanent  sense  of  weakness  and  exhaus- 
tion, the  lack  of  power  and  debility  frequently  present  a  striking 
contrast  to  the  relatively  good  general  appearance  and  the  abun- 


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THE   THYMUS    AND    THYROID  261 

dance  of  abdominal  fat."  On  examination  of  the  abdominal  wall 
one  is  sometimes  impressed  with  the  excessive  tenderness  which  is 
present. 

The  Mesenteric  Glands. — The  mesenteric  glands,  even  though 
enlarged,  do  not  of  themselves  cause  much  pain,  unless  the  enlarge- 
ment is  excessive,  when,  by  encroachment  upon  neighboring  struc- 
tures and  interference  with  their  function,  they  may  indirectly 
be  the  cause  of  pain  production.  In  tuberculosis,  when  the  mesen- 
teric glands  reach  an  enormous  size,  the  patient  often  complains 
of  aching  and  distress,  or,  as  frequently  expressed  by  negro  sub- 
jects, "a  misery  in  the  abdomen."  This  misery  becomes  an  acute 
pain,  should  the  gland,  becoming  degenerated  and  caseous,  sud- 
denly rupture  and  cast  its  contents  into  the  peritoneal  cavity.  The 
pain  now  assumes  the  characteristics  of  that  due  to  general  peri- 
toneal irritation. 

The  Thymus  and  Thyroid. — The  thymus  and  thyroid  are  en- 
tirely without  pain  production,  unless  they  become  acutely  in- 
flamed, when  pain  phenomena  appear.  Frequently  in  thyroid 
tumors  and  in  disease  of  the  gland  pain  is  felt  in  the  occiput,  in 
the  shoulder  and  back  of  the  ear,  due  to  irritation  (pressure)  of 
the  posterior  auricular.  In  one  case  pain  was  complained  of  over 
the  second  dorsal  spine. 

In  Hodgkin's  disease  pain  in  the  arms  is  very  common,  be- 
cause of  the  pressure  exerted  upon  the  nerves  in  the  axilla.  In 
the  same  way  pain  may  be  felt  in  the  lower  limbs  from  pressure 
upon  the  anterior  crural  nerve  by  enlarged  inguinal  glands. 


CHAPTER  XIV 


EEGIONAL  PAINS 


As  an  aid  to  a  quick  orientation  of  the  canse  of  pain  which  is 
felt  in  a  special  area,  the  body  may  be  divided  into  different  re- 
gions, as  the  head,  neck,  arms,  chest,  abdomen,  and  the  extremities. 
Each  of  these  will  be  fully  discussed  under  special  headings,  but 
at  first  a  brief,  general  review  of  the  different  pains  in  these 
regions  and  their  significance  will  be  undertaken. 

THE  HEAD 

The  head  is  a  most  important  localizing  center  for  pain,  for  it 
seems  that  here  all  the  aches  and  ills  of  the  human  body  converge 
to  bring  torment  and  suffering  to  the  unfortunate  individual. 
Head  pain  is  partially  considered  under  headache,  which  includes 
the  pains  felt  in  the  cranial  part  of  the  head,  but  headaches  do 
not  include  face  pains.  These  are  very  important,  as  they  in- 
clude one  of  the  most  sinister  of  all  human  ills,  namely,  trigeminal 
neuralgia  (tic  douloureux).  Its  pains  occur  in  the  forehead,  the 
cheek  and  over  the  lower  jaws.  There  are  well-defined  spots  of 
maximum  tenderness,  which  are  shown  in  the  drawings.  Of 
other  important  causes  of  face  pains,  sinus  disease  probably  ranks 
next.  These  sinus  diseases  include  the  frontal,  ethmoid  and  an- 
trum of  Highmore.  When  any  of  these  structures  is  affected, 
pain  is  complained  of  by  the  patient,  and  at  the  same  time  tender- 
ness is  marked  over  the  diseased  area.  Should  tenderness  not  be 
present  in  the  area  in  which  the  patient  complains  of  pain,  it 
indicates  that  the  pain  is  a  referred  pain  from  some  distant  region. 
262 


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264 


REGIONAL   PAINS 


A  good  example  of  this  is  pain  in  the  temples,  referred  from 
carious  teeth.  Reference  to  Figures  61  and  62  will  do  more  to 
localize  these  different  pain  areas  and  their  significance  than  an 
entire  volume  of  description.     Head  pains  referred    (reflected) 


Lithemia 
Anemia 
Neurasthenia 
Ovarian 
Mental  tire 
Infectious  diseases 

Typhoid 

Influenza 

Malaria 

Small-pox 
Meningitis 
Brain  tumor 
Coryza 


Toothache 
Supramaxillary 
inflammation 


Neuralgia 

Inf.  dental  branch 


Fig.  62. — Pain  Areas  in  the  Head. 


4 
Epilepsy 
Uterine  disease 
Pregnancy 
Anemia 
Meningitis 
Ovarian  disease 
Hysteria 
5 
Migraine    man- 
ner of  radia- 
tion 
6 
Arteriosclerotic 
headache 
■7 
Ethmoid.       Ar- 
rows indicate 
the    direction 
of  radiation 
8 
Orbital  headache 
Typhoid  fever 
Eye  strain 
Anemia 

Inflammation  of 
eye 

9 
Point     of     ten- 
derness in  in- 
f  r  a-o  r  b  i  t  a  1 
neuralgia 
10 
Antrum  disease 

11 
Point  of  tender- 
ness in  mental 
neuralgiH 
Periostitis     inf. 


from  abdominal  and  thoracic  organs  are  described  in  the  chapters 
under  their  respective  headings. 

The  most  important  of  the  local  head  pains  is  headache,  or, 
as  it  should  be  called,  head  pain.  When  a  patient  complains  of 
headache,  he  should  always  be  asked,  "Is  it  a  pain,  or  is  it  only  a 
sense  of  pressure  ?"  If  it  is  a  sense  of  pressure,  the  consideration 
will  be  entirely  different  from  that  of  true  head  pain. 

Sense  of  Pressure  in  Head. — Edinger  has  graphically  dis- 
cussed this  condition,  especially  in  its  relation  to  neurasthenia.  He 
notes  that  "the  pressure  is  felt  in  the  top  of  the  head,  and  is  espe- 
cially severe  in  the  morning.  It  generally  continues  all  day, 
though  it  may  lessen  toward  night.     This  head  pressure,  which  is 


THE    HEAD  265 

not  a  pain,  is  particularly  a  characteristic  of  tired  persons ;  those 
who  have  overworked,  either  physically  or  mentally,  and  those 
whose  hours  of  labor  are  too  long  or  too  continuous ;  those  who  are 
hereditarily  weak ;  and  those  who  have  suffered  from  severe  dis- 
ease (influenza)  and  have  exerted  themselves  too  soon  thereafter. 

If  the  sensation  is  described  by  the  patient  as  a  pain,  head- 
aches should  then  be  considered. 

Head  Pain. — In  the  diag-nosis  of  headache  it  is  well  to  ascer- 
tain first  whether  the  pain  is  unilateral  or  bilateral.  If  it  is  bi- 
lateral, it  generally  is  an  indication  that  the  underlying  cause 
is  of  systemic  origin,  while  if  it  is  unilateral,  as  a  rule  it  is  an  in- 
dication that  the  cause  or  causes  acting  to  produce  it  are  also  uni- 
lateral in  their  origin.  Where  headache  is  unilateral,  it  is  always 
wise,  before  making  a  more  extended  search,  to  examine  the  head 
for  local  causes,  such  as  inflammations,  or  to  examine  the  organs 
located  in  or  associated  with  the  skull,  such  as  the  eye,  the  ear,  the 
nose,  the  teeth,  and  also  the  throat,  which  in  many  cases  is  at 
fault. 

The  following  outline  of  the  principal  causes  of  head  pain 
may  be  of  value  in  the  diagnosis.  The  classification 
used  is  based  upon  an  anatomico-physiologic  basis.  Accord- 
ing to  this,  head  pains  may  be  divided  into  two  great 
classes:  (1)  those  of  extracranial  origin,  and  (2)  those  of 
intracranial  origin. 

Head  Pains  of  Extracranial  Origin. — Extracranial  head  pains 
are  caused  by  lesions  of  the  skin,  muscles,  tendons,  bones,  and 
nerves.  The  shin  includes  the  epidermis  and  subcutaneous  tis- 
sues, and  is  the  seat  of  pain  in  neuralgia  and  superficial  inflam- 
matory lesions.  Excessive  weight  of  hair  may  be  the  cause  of 
severe  and  chronic  headache. 

The  muscles  are  the  seat  of  pains,  the  result  of  such  metabolic 
disorders  as  occur  in  rheumatism,  gout  and  diabetes.  Inflamma- 
tion likewise  may  be  a  cause  of  local  pain.  In  this  connection 
it  is  well  to  mention  a  condition  described  by  many  Avriters,  in 
which  headache  is  due  to  indurative  processes,  occurring  in  the 
muscles  of  the  bead   and   neck.       Edinger   claims  that,   though 


266 


REGIONAL   PAINS 


almost  unknown,  the  indurative  variety  of  head  pain  is  probably 
the  most  common  of  all  headaches.     In  those  suffering  from  it,  it 
is  found  that  at  the  insertions,  or  within  the  bodies  of  the  muscles 
of  the  head  and  neck,  there  appears  a  thickening  w^hich  at  first  is 
transient  and  then  later  becomes  constant.     This  thickening,  prob- 
ably of  chronic  inflammatory 
origin,   irritates   tlie   sensory 
nerve    fibers   supplying    the 
part,  and  thus  produces  pain. 
The    pain    occurs    in    parox- 
ysms, which  may  be  brought 
on  by  emotional  disturbances, 
physical   or   mental   fatigue, 
sudden  exposure  to  cold,  in- 
sufficient drying  after  wash- 
ing the  hair,  a  stay  in  bad- 
ly ventilated  places,  and  the 
approach  of  damp  or  chilly 
weather  or  storms.    The  par- 
oxysms are  least  common  in 
summer    and   most  frequent 
Fig.  63. — Figure  Illustrating  the     in  the   fall   and   the   spring. 
Places  Where  Induration  Takes     i^    ^he    development    of   the 
Place. 
These  areas  are  tender  to  pressure.         induration   three    stages    can 

be  defined.  In  the  first  stage 
a  swelling  of  a  soft,  yielding  consistency,  often  present  in  the 
bodies  of  the  muscles,  makes  its  aj^pearance.  A  puffiness  to  the 
touch  is  now  felt  at  this  point;  then,  in  a  short  time,  a  slightly 
elastic  resistance  develops,  as  though  some  organization  had  taken 
place ;  and  finally  an  induration,  in  which  there  is  an  absence  of 
elasticity,  occurs.  Organization  has  now  advanced  to  the  stage 
at  which  a  substance  of  cartilaginous  consistency  presents  itself  to 
the  examiner.  The  older  these  thickenings  are,  the  harder  they 
become  and  the  more  resistant  they  are  to  treatment. 

The   symptoms    are   characteristic.      Attacks    of   pain   occur, 
which  at  first  are  slight  and  infrequent,  and  then  gradually  be- 


THE    HEAD  267 

come  more  frequent,  greater  in  severity  and  longer  in  duration; 
Sometimes  they  are  of  a  dull,  aching  type,  and  are  almost  con- 
stant; again,  they  are  sharp  and  fleeting.  They  occur  in  various 
parts  of  the  head,  the  location  depending  upon  the  site  of  the 
local  enlargements,  over  which  they  are  usually  found.  They  may, 
however,  radiate  to  other  joarts.  Local  pressure  often  gives  relief. 
Before  an  attack  the  enlargements  become  swollen  and  sensitive. 

The  symptoms  associated  with  this  disorder  are  the  marked 
susceptibility  of  the  patient  to  colds,  depression  of  spirits,  and  to 
mental  torpor.  Gastrointestinal  disturbances,  toxic  in  character, 
occur,  and  spasms  in  the  leg-muscles  and  myalgia  in  different 
parts  of  the  body  take  place.  Ilypersensitiveness  of  the  teeth  and 
a  pyorrhea  alveolaris  are  also  seen,  and  on  forcible  twisting  or 
turning  of  the  neck  there  is  intense  pain  at  the  insertions  or  along 
the  bodies  of  the  neck-muscles.  Local  tenderness  over  the  sites  of 
the  enlargements  almost  always  is  present.  •  It  is  most  common 
at  the  insertions  of  the  trapezii,  scaleni,  splenii  and  sternomastoid 
muscles.  Hypersensitive  points  are  often  found  round  the  base 
of  the  skull,  from  one  mastoid  process  to  the  other,  and  on  the 
spinous  process  of  the  cervical  vertebrje,  j^articularly  the  upper 
cervical  vertebrae.     The  supraorbital  region  also  is  often  involved. 

These  indurative  headaches  are  to  be  diagnosed  from:  (1) 
Meningitis,  in  which  fever  is  present  and  induration  and  hyper- 
sensitiveness  are  absent. 

(2)  Migraine,  in  which  sensitive  aura  are  present,  indura- 
tion and  local  hypersensitiveness  are  absent,  nausea  and  vomiting 
are  present,  and  no  relief  comes  from  massage.  While  hereditary 
migraine  begins  in  early  youth,  indurative  headache  appears  in 
later  life. 

(3)  Bone  diseases,  such  as  inflammation,  caries,  gummata 
and  tuberculosis  should  also  be  carefully  diagnosed,  as  they  often 
give  rise  to  local  head  pain  and  indurative  areas.  A  careful  study 
of  the  general  symptom-complex  will  often  clarify  the  situation. 
As  a  rule,  though,  the  indurative  headaches  are  very  common. 
They  are  very  easy  to  differentiate,  because  of  their  local 
character. 


268  REGIONAL   PAINS 

That  long-continued  contraction  of  a  gTonp  of  head-muscles 
may  cause  pain  is  possible.  Thompson  (630)  describes  such 
headaches  which  arise  from  the  long-continued  contraction  of  the 
occipito-frontalis  muscle,  as  the  result  of  a  strong  sensory  impres- 
sion, coming  from  the  eyes,  ears,  or  other  channels  of  sensation. 
They  may,  however,  be  produced  only  as  a  result  of  the  irritation 
of  cold  and  strong  winds. 

Nerves. — The  head  pains  due  to  nerve  involvement  are  to  be 
classed  under  neuralgias  and  neuritides.  There  is  also  a  local 
irritation  which  has  not  progressed  to  the  stage  of  inflammation. 

Neuralgia,  which  means  nerve  pain  (for  a  complete  descrip- 
tion see  under  Neuralgia),  is  a  rather  frequent  cause  of  pain  in 
the  head.  In  it  pressure  points  can  be  found,  corresponding  to 
the  emergence  of  sensory  nerves  from  the  skull.  The  nerves  most 
frequently  involved  are  the  trigeminal  and  the  cervico-occipital 
branches  of  the  cervical  plexus.  Neuralgia  is  frequently  the  result 
of  wasting  diseases,  malnutrition,  exposure,  poor  hygienic  condi- 
tions, rheumatism,  gout,  diabetes,  anemia,  chronic  malaria  and 
acute  infectious  disease. 

Neuritis,  a  somewhat  allied  condition,  differs  from  neuralgia 
in  being  a  much  more  active  inflammation  of  the  nerves  or  nerve 
sheaths.  In  it  the  nerve  is  painful  to  pressure,  muscular  twitcli- 
ings  occur,  and,  if  the  condition  continues  long  enough,  a  final 
atrophy  and  paralysis  of  the  related  muscles  may  result. 

Head  pain  may  also  be  induced  by  the  products  of  metabolism/ 
which  act  locally  upon  the  muscles  of  the  scalji  and  produce  pain 
by  irritation  of  the  sensory  nerves  in  the  same  manner  as  it  is 
produced  in  gout  and  rheumatism.  Especially  is  this  liable  to 
happen  should  the  resistance  of  the  muscles  have  been  previously 
reduced  by  exposure  to  cold  or  drafts.  In  neuralgias  and  inflam- 
mations there  is  always  a  certain  amount  of  associated  hyperes- 
thesia, the  affected  part  being,  in  many  cases,  exquisitely  tender. 

In  addition  to  headaches  due  to  local  causes  are  those  which 
are  the  result  of  conditions  present  at  a  distance  from  the  area  in 
which  pain  is  felt.  These  are  classified  as  projected,  reflex,  or  re- 
ferred headaches.     Projected  headache  is  the  result  of  pressure 


THE    HEAD  269 

upon  the  cranial  nerves,  either  in  their  extracranial  or  intra- 
cranial course.  Such  pressure  may  be  due  to  tumors,  caries  of 
bone  (especially  caries  or  periostitis  of  the  bone  at  the  foramina 
of  exit)  and  to  foreign  bodies. 

Reflex  headache  is  due  to  a  stimulus  carried  through  the 
nervous  system  from  some  distant  organ.  In  these  headaches  the 
action  is  upon  the  nerve  centers,  or  nerves,  either  indirectly 
through  adjacent  nerve  centers,  or  directly  by  the  action  of  irri- 
tating bodies  (toxins  of  disease  and  organic  or  inorganic 
poisons).  The  fifth  nerve  seems  to  be  especially  subject  to  irri- 
tation from  extraneous  causes,  and  the  part  that  seems  to  be  most 
commonly  affected  is  the  Gasserian  ganglion. 

Referred  headache  is  the  result  of  a  reference  of  stimuli  along 
associated  or  related  nerve  pathways,  as  is  exemplified  in  the 
frontal  headache  following  immediately  after  the  drinking  of  ice- 
water,  etc. 

Head  Paixs  of  Intracranial  Origin. — The  intracranial 
causes  of  headache  are :  Meningeal  changes,  functional  and  or- 
ganic; cerebral  toxemia;  cerebral  anemia;  cerebral  congestion; 
increase  of  cerebrospinal  fluid. 

Meninges  as  a  Cause  of  Headache. — Stretching  and  pressure 
exerted  on  the  meninges  is  the  most  important  cause  of  headache,^ 
and  produces  the  most  severe  and  persistent  pain,  as  in  cere- 
bral tumor ;  here,  owing  to  the  general  increase  of  pressure  from 
the  growth,  the  headache  is  apt  to  be  diffuse.  However,  when 
the  cortex  membranes  are  involved,  the  pain  becomes  localized ; 
and  this  localization  is  of  the  utmost  value  in  defining  the  site  of 
the  tumor. 

The  general  cause  of  meningeal  stretching  and  traction  is 
pressure  from  underlying  structures.  The  piaarachnoid  is  prob- 
ably not  supplied  with  sensory  nerves,  and  it  is  very  likely  that 
its  only  nerve  supply  consists  of  those  supplying  the  blood  vessels. 
Therefore,  in  cases  of  leptomeningitis,  it  is  the  congestion  inci- 

1  The  meninges  seem  to  be  almost  insensitive  to  the  ordinary  stimuli, 
as  when  the  skull  is  opened  under  local  anesthesiae  they  may  be  touched, 
pinched  or  cut,  without  the  patient  complaining  much  of  pain, 


270  REGIONAL   PAINS 

dental  to  the  inflammation  that  causes  pressure  upon  the  dura 
and  its  nerve  filaments,  and  so  produces  pain. 

Stretching  and  pressure  on  the  meninges  may  also  be  caused 
by  an  increase  in  the  cubical  contents  of  the  cranial  cavity,  such 
as  occurs  by  an  increase  in  the  brain  substance  from  new  growths, 
abscesses,  and  increase  in  the  fluids  of  the  brain  (blood  and  cere- 
brospinal fluid). 

Increase  in  brain  substance  is  foimd  in  new  growths,  such  as 
tumors  of  the  brain.  These  cause  pain  by  increasing  the  intra- 
cranial pressure.  This  they  do  in  two  ways:  (a)  by  an  increase 
in  the  intracranial  contents,  which,  owing  to  the  pressure  of  their 
mass,  cause  an  increase  in  the  intraventricular  pressure,  and  (b) 
by  raising  the  intraventricular  pressure,  either  by  shutting  off 
the  means  of  exit  of  the  intraventricular  fluid  by  blocking  the 
foramina  of  communication  between  the  ventricles  and  the  suba- 
rachnoid spaces,  or  else,  by  pressure  on  the  veins  of  Galen.  A 
loose  fibroma  in  the  lateral  ventricle  may  also  act  as  a  plug  and 
thus  prevent  the  escape  of  cerebrospinal  fluid,  and  cause  intoler- 
able headache,  optic  neuritis,  coma  and  death. 

Pain,  in  some  cases,  in  which  the  tumor  is  cortical  or  sub- 
cortical, is  produced  by  the  growth  pressing  directly  upon  the 
meninges,  and  in  this  way  squeezing  the  terminal  nerve  filaments 
incorporated  in  its  substance.  Tumors  of  the  posterior  fossa  of 
the  cranium  probably  cause  the  most  pain. 

Diagnostic  symptoms  of  tumors  of  the  brain  are  pain,  which, 
in  cerebral  tumor,  owing  to  the  general  increase  of  blood  pressure 
from  the  growth,  is  as  a  rule  diffused.  When  the  cortex  mem- 
branes are  involved,  the  pain  becomes  localized,  and  this  locali- 
zation is  of  the  utmost  value  in  defining  the  site  of  the  lesion. 
When  the  pain  becomes  circumscribed,  it  is  most  often  confined 
to  the  forehead  or  to  the  occipital  region.  Accompanying  the  pain 
there  are  disturbance  of  sensation  and  motion,  choked  disc,  rigidity 
of  the  pupils,  vomiting  of  a  projectile  character  (with  an  entire 
absence  of  gastric  symptoms)  and  dizziness.  Sometimes  symp- 
toms of  headache  may  be  almost  entirely  absent  in  brain  tumor, 
a?  in  a  case  reported  by  Edinger,  in  which,  on  autopsy,  a  tumor 


THE    HEAD  271 

was  found  in  the  Island  of  Eeil  of  a  patient,  who  had  had  head- 
ache only  a  short  time  before  death. 

Brain  tumors  may  be  syphilitic,  tnberculons,  hydatid,  carci- 
nomatous, sarcomatous,  or  osseous  formations  within  the  cranial 
vault. 

Brain  abscess  causes  headache  in  the  same  manner  as  do 
tumors. 

Organic  Meningeal  Changes. — Organic  meningeal  changes 
due  to  adhesions,  inflammations  and  hemorrhages  cause  head- 
aches. Adhesions  between  the  dura  and  the  cranium  are  often 
the  cause  of  severe  pain,  localized  over  the  affected  area.  Local- 
ized head  pain  may  also  be  caused  by  syphilis  and  trauma,  or  it 
may  be  the  result  of  inflammation.  The  inflammations  causing 
these  headaches  are  of  two  types : 

(1)  Pachymeningitis  interna,  which  is  very  common  in  old 
people,  and  quite  frequently  accompanied  with  small  and  minute 
hemorrhages.  The  headache  frequently  is  introduced  by  vomit- 
ing, which  sometimes  occurs  in  paroxysms,  wntli  brief  intervals. 
Occasionally  it  is  combined  with  a  disturbance  of  consciousness 
or  of  paralysis  of  some  cranial  nerve  (see  page  180).  (2)  Acute 
meningitis  gives  rise  to  an  increased  blood  pressure,  which,  in 
turn,  causes  an  outpouring  of  serous  fluid  into  the  meninges.  This 
produces  pressure  on  this  membrane  and  on  the  terminal  sensory 
nerve  filaments.  It  may  also  cause  headache  by  involving  the 
nerve  filaments  and  meningeal  endings  in  the  inflammatory 
process. 

Toxemic  Headaches. — These  are  due  to:  (1)  Exogenous 
poisons,  as  alcohol,  lead,  iron  ether,  nitroglycerin,  amyl  nitrite,  or 
arsenic,  and  (2)  endogenous  poisons,  as  the  toxins  of  pneumonia, 
typhoid  fever,  influenza,  small-pox,  chronic  gastritis,  chronic 
Bright's  disease,  diabetes,  cirrhosis  of  the  liver,  cerebral  syphilis, 
gout,  hyperthyroidism,  starvation,  and  possibly  diseases  due  to 
alimentary  disturbances.  Toxins  act  by  altering  the  intracerebral 
pressure  through  their  action  on  the  vasomotors  and  possibly  also 
directly  upon  the  sensory  filaments  in  the  meninges.  In  addition 
to  the  reflex  head  pain,  some  slight  sluggishness  of  intellect  is  gen- 


272  REGIONAL    PAINS 

erally  associated  Avith  these  conditions,  and  this  may  progress  to 
delirium. 

Of  the  toxemias  the  starvation  products  due  to  nutritional 
defects,  caused  bv  anemia,  are  the  most  frequent  cause  of  head 
pain.  The  head  pain  which  they  produce  is  mostly  of  local  origin 
and  has  been  ascribed  to  a  lack  of  nutrition  of  the  trigeminal 
nerves,  or,  according  to  Xeuman,  to  a  disturbance  of  the  brain 
cortex.  This  disturbance  leads  to  pain.  This  manner  of  pain  pro- 
duction explains  why  the  headache  is  relieved  when  the  patient 
reclines,  for,  in  doing  so,  he  increases  the  blood  supply  to  the 
brain  and  incidentally  the  nutrition. 

Anemia. — The  diag-nostic  criteria  associated  with  anemic 
headaches,  which,  in  a  way,  are  starvation  headaches,  are  pain, 
generally  vertical,  and  made  easier  on  the  patient  reclining;  pal- 
lor, especially  marked  on  the  lips ;  disturbed  sleep ;  drowsiness ; 
edema  of  the  ankles ;  drooping  of  the  eyelids ;  and  feeble  carotid 
pulsation,  a  symptom  which  is  of  great  diagnostic  importance. 
Lenhartz  (Munich  Med.  Woch.,  1876,  Nos.  8-9)  showed  that  the 
headache  and  dizziness  of  chlorosis  are  associated  with  an  in- 
crease in  the  subarachnoid  pressure ;  therefore,  it  is  this  increase 
in  pressure  and  (in  many  cases)  not  the  anemia  which  is  the 
cause  of  the  headache. 

Congestion. — Cerebral  congestion  seems  to  be  a  true  cause  of 
headache.  Edinger  claims  that  the  headache  of  migraine  is  of  this 
type,  i.  e.,  that  it  is  due  to  a  vasomotor  congestion.  For  the  expla- 
nation of  the  causes  of  these  headaches,  see  under  Vasomotor, 
Paralytic  Headache,  which  is  described  under  Headache  of 
Chronic  Origin. 

Cerebral  congestion  leads  to  on.  increase  in  the  amount  of  fluid 
in  the  hrain.  This  increased  amount  may  be  the  result  of  an 
increase  in  the  amount  of  blood  in  the  b^'ain  substance  (edema), 
or  in  the  quantity  of  the  cerebrospinal  fluid.  The  increase  in  the 
amount  of  blood  in  the  brain  is  the  result  of  an  increase  in  the 
intracranial  blood  pressure,  or  of  venous  congestion. 

Increased  arterial  pressure  in  the  cranium  may  or  may  not 
be  associated  with  increased    (systolic  mean)    arterial  pressure, 


THE   HEAD  273 

In  some  cases  an  increased  arterial  supply  to  the  brain  is  due  both 
to  an  increased  heart  action  and  to  an  interruption  to  the  return 
flow  through  the  venous  channels.  Some  causes  of  increased  intra- 
cranial blood  pressure,  which  may,  in  certain  conditions,  incite 
head  pain,  are  the  following :  stooping,  lifting  weights,  sitting  up 
suddenly,  lying  do^vn  quickly,  the  horizontal  position,  hard  strain- 
ing at  stool,  physical  exertion,  running  and  extreme  heat. 

Predisposing F actors.- — There  are  certain  factors  wdiichreflexly 
act  upon  the  blood  vessels  or  the  vasomotor  centers  and  cause  such 
a  lessening  in  control  that  slight  causes,  wdiich  otherwise  would 
have  no  action,  act  upon  the  cerebral  centers,  and  lead  to  a  cerebral 
congestion.  These  factors  are  mental  excitement,  anger,  or  men- 
tal labor  (severe),  acting  as  a  reflex  cause  of  neurasthenia,  which 
in  turn  acts  principally  as  a  predisposing  factor  in  headache  pro- 
duction. Other  reflex  and  clinical  factors  are  found  in  alcoholics, 
coffee  and  tea  drinkers,  and  in  those  suffering  from  fevers.  Sun- 
stroke and  rapid  chilling  of  the  surface,  as  in  colds,  also  have  the 
same  effect.  In  come  cases  there  is  a  further  lessened  resistance 
to  the  above  acting  causes,  because  of  a  vasomotor  ataxia  due  to 
nicotinism  (Schmidt).  In  headache  due  to  increased  intracranial 
arterial  pressure  the  pain  generally  is  of  a  throbbing  nature, 
the  throbbing  being  due,  perhaps,  to  a  backward  and  forward  flow 
of  the  cerebrospinal  fluid.  The  pain  is  accompanied  by  a  fulness 
of  the  head  especially  marked  on  coughing  or  on  any  sudden 
exertion.  A  flushed  face,  injected  eye  grounds,  general  irrita- 
bility, sensory  disturbances  and  increased  heart  action  also  accom- 
pany this  condition.  There  is  also  a  form  of  arterial  congestion 
due  to  a  vasomotor  paralysis  in  which  pain  is  present  in  all  parts 
of  the  head,  but  is  especially  severe  on  the  top  and  in  the  temples, 
where  it  seems  as  though  the  head  would  burst.  There  is  also  a 
painful  sense  of  pressure  behind  the  eyes,  which  seem  to  bulge 
forward.  Periods  of  freedom  from  pain  intervene;  then  there 
are  recurrences,  often  just  before  the  menses,  or  when  the  atmos- 
phere is  heavy. 

In  headache  due  to  general  hyper  hlood-tension,  Matthew 
(Quarterly  Journal  of  Medicine,  1909,  II,   261)   found  that  a 


274  REGIONAL   PAINS 

reduction  of  about  30  mm.  Hg  in  the  blood  pressure  was  almost 
invariably  followed  by  an  alleviation  of  the  head  symptoms. 

Another  cause  of  hypertension  headache  is  the  local  increase  in 
blood  pressure,  the  result  of  inflammation,  as  in  meningitis.  Here 
the  pain  is  generally  associated  with  a  slow,  strong  pulse,  though 
no  rise  in  the  mean  arterial  pressure  may  be  noted.  In  this  it 
differs  from  aortic  regurgitation,  which  also  causes  headache,  but 
in  which,  although  there  is  a  sudden  strong  pulse  (high  systolic 
pressure),  the  mean  arterial  pressure  is  reduced.  A  third  cause, 
the  result  of  cerebral  arteriosclerosis,  is  the  elevation  in  the 
cerebral  systolic  pressure,  which  may  be  high,  though  the  mean 
arterial  pressure  may  be  normal. 

Moleen  writes :  "Of  the  general  symptoms  of  cerebral  arterio- 
sclerosis, headache  stands  first.  It  is  usually  dull,  not  throbbing, 
and  quite  often  is  described  as  a  feeling  as  though  a  tight  band 
were  compressing  the  head.  It  occurs  most  frequently  in 
the  morning  after  walking  about,  and  diminishes  as  the  day 
advances,  except  in  syphilitic  arteriosclerosis,  in  which  it  is 
usually  most  severe  at  night.  Dizziness,  or  vertigo,  as  a  symptom, 
is  next  in  importance  to  pain.  I^umbness,  tingling,  twitching, 
weakness  in  a  limb,  or  in  one-half  of  the  body,  and  disturbances 
in  articulation  are  also  common." 

Headache  may  be  caused  by  increased  venous  pressure^  as  well 
as  by  increased  arterial  pressure ;  or  both  may  interact  to  produce 
increased  intracranial  pressure.  Headaches  of  the  first  type  are 
present  when  there  is  any  obstruction  to  the  return  circulation,  as 
in  tricuspid  regurgitation  (which  produces  back  pressure), 
thyroid  enlargement  (producing  static  back  pressure),  sinus 
thrombosis,  and  paroxysms  of  coughing.  Tight  neck  bands  and 
epilepsy  (Knowlton)  may  also  cause  headache. 

General  Consideration  of  Hypertension  Headaches. — 
Hypertension  headaches  are  very  severe  and  usually  are  badly 
borne.  It  is  most  likely  that  in  all  hypertension  headaches  there 
is  a  supersensibility  of  the  nerves  supplying  the  dura,  and  thus 
more  cognizance  than  normal  is  taken  of  changes  in  intracranial 
pressure.    In  these  headaches  the  pain  is  eased  by  the  patient  draw- 


THE   HEAD  275 

ing  his  head  far  backward  and  burying  it  in  the  bed  clothes.  If 
the  neck-muscles  are  in  a  state  of  tonic  contraction,  we  may  pre- 
sume the  lesion  causing  the  condition  to  be  of  an  inflammatory 
nature,  probably  one  affecting  the  meninges.  If  this  is  the  case, 
bending  the  head  forward  seems  to  increase  the  pain,  and  rotation 
is  also  ]3ainful,  the  pain  being  in  the  nape  of  the  neck,  and  fre- 
quently on  the  side  opposite  to  that  toward  which  the  rotation  has 
taken  place  (Schmidt).  Swallowing,  as  well  as  lying  down,  at 
times  causes  pain.  The  patient  often  attempts  to  fix  the  head 
with  the  hands,  so  that  movement  cannot  take  place.  Hyperten- 
sion headaches  are  quickly  relieved  by  the  taking  of  a  purgative. 
This  would  hardly  happen  if  the  headache  were  due  to  a  toxemia, 
in  which  case  the  headache  would  last  for  some  little  time,  un- 
til the  toxic  material  could  be  removed.  Xow,  it  behooves  us  to 
ask,  how  a  purgative  so  quickly  relieves  the  headache.  It  is  rea- 
soned by  Schmidt  that  intestinal  stasis  causes  meteorism,  and  that 
this  in  turn  causes  "stasis  in  the  superior  vena  cava  and  in  the 
cerebral  veins  through  the  restriction  of  the  respiratory  venous 
aspiration" ;  and  purgation  causes  a  revulsion  in  this  condition, 
and  a  normal  respiratory  circulatory  activity.  He  also  remarks 
"that  the  important  part  played  by  normal  intestinal  "peristalsis  in 
facilitating  the  venous  circulation  in  the  jDortal  district  must  not 
be  forgotten.  The  headache  may  be  temporarily  increased  if  the 
act  of  defecation  is  accomj^anied  by  considerable  straining" 
(Schmidt,  p.  43).  A  point  of  value  in  diagnosing  increased  ven- 
tricular pressure  is  that  the  pain  of  increased  ventricular  pressure 
is  always  referred — while  that  due  to  meningitis  or  tumor  (menin- 
geal), etc.,  is  always  localized  to  the  area  involved. 

Associated  with  hypertension  headaches  are  changes  in  the 
fundus  of  the  eye,  such  as  dilatation  of  the  veins,  hemorrhage  into 
the  retina,  and  choked  disc,  all  of  which  are  due  to  mechanical 
agents.  There  are  also  present  mild  inflammatory  lesions,  partly 
due  to  obstruction  of  the  lymphatic  return  flow. 

Pressure  points  (see  Neuralgia,  Fig.  44)  can  often  be  dem- 
onstrated in  the  area  of  distribution  of  occipital-trigeminal  nerves. 
Hiccoughs,  vomiting,  abnormalities  in  pulse  and  respiration,  pos- 


276  REGIONAL    PAINS 

sibly  due  to  vagus  involvement,  are  also  found.  The  spots  seen 
dancing  before  the  eyes  are  due  to  optic  nerve  involvement,  while 
the  buzzing  in  the  ears  is  the  result  of  involvement  of  the  audi- 
tory nerve. 

Increased  intracranial  pressure  is  often  evidenced  by  a  visible 
distention  of  the  veins  of  the  brow  or  of  the  scalp.  The  degree 
of  stasis  may  be  fairly  well  judged  by  the  magnitude  of  the  dila- 
tation of  the  venules  of  the  upper  eyelid  (Gushing).  Where  in- 
creased intracranial  pressure  is  present,  repeated  examination  of 
the  urine  should  be  made  in  order  to  detect,  if  possible,  the 
presence  of  a  nephritis. 

Among  other  associated  symptoms  of  tension  headaches  are 
great  debility,  disinclination  for  any  kind  of  work,  anorexia,  and 
distressing  dreams  with  fright  on  awakening.  Actual  hallucina- 
tions are  occasionally  present ;  edema  of  the  cortex  of  the  skull 
sometimes  occurs ;  red  blotches  at  times  cover  the  entire  surface 
of  the  body,  and  the  strise  of  the  skin,  which  are  produced  by 
stroking  with  the  finger,  often  persist  much  longer  than  the  normal 
time.  Thunderstorms  aggravate  or  initiate  the  pain.  Headaches 
of  this  variety  should  be  diagnosed  from  those  due  to  brain  tumor 
by  an  eye  examination.  Choked  disc  is  present  in  tension  (tumor) 
headache,  and  is  absent  in  vasomotor  paralytic  headache. 

Head  pain  may  also  be  due  to  an  actual,  as  well  as  a  relative, 
increase  of  the  cerebrospinal  fluid.  This  increase  may  be  local- 
ized to  either  the  meninges  or  the  ventricles.  Increase  in  the  men- 
ingeal fluid  without  an  accompanying  inflammation  may  be  due 
to  anemia  (such  as  chlorosis  or  constipation  with  acetonemia). 
Increase  in  the  ventricular  fluid  may  be  caused  by  an  increased 
production  of  the  fluid,  or,  if  the  production  of  the  fluid  is  normal, 
by  a  blocking  of  the  foramina  of  exit  (Foramen  Magnus  or  the  Ac- 
queduct  of  Sylvius),  which  causes  an  accumulation  of  fluid  in 
the  ventricles.  Accumulation  of  fluid  may  occur  in  any  of 
the  cavities  of  the  brain,  from  a  blocking  of  their  foramina  of 
exit  by  new  growths,  inflammatory  exudates,  or  foreign  bodies. 
That  a  foreign  body  may  cause  such  an  obstruction  is  proven  by 
the  many  reported  cases  in  which  the  removal  of  an  extraneous 


THE   HEAD  277 

substance,  such  as  a  bullet  from  a  position  in  the  brain  where 
it  was  producing  obstruction,  relieved  the  pressure  and  cured  the 
headache.  Angioneurotic  hydrocephalus  is  also  a  cause  of  head 
pain  which  is  due  to  an  accumulation  of  the  cerebrospinal  fluid 
in  the  ventricles.  Cerebral  compression  may  also  be  the  cause  of 
an  internal  hydrocephalus,  and  thus  cause  head  pain.  Gushing, 
in  speaking  of  cerebral  compression  the  result  of  tumor  growth, 
says  that  he  succeeded  in  demonstrating,  in  the  dog,  that  the 
longitudinal  sinus  may  completely  colla2:)se  at  an  early  stage  of 
compression  with  a  venous  stasis  of  high  degree.  If  there  is 
increased  tension,  from  any  source,  a  similar  collapse  may  be  pro- 
duced in  the  sinus  rectus,  with  stasis  in  the  vena  galena,  and  this 
produces  an  internal  hydrocephalus  withoi:t  direct  implication  of 
these  vessels  by  pressure  from  a  neighboring  growth.  This  in- 
ternal hydrocephalus  produces  pressure  and  traction  on  the  dura 
mater  which  results  in  head  pain. 

Reflex  causes  of  headache  are  the  last  to  be  considered,  but 
they  are  not  by  any  means  the  least  important.  Reflex  headaches 
are  due  principally  to  organic  disturbances  of  the  uterus,  ovary, 
eyes  (iritis,  glaucoma,  chronic  eye  strain),  sinus  disease  (nasal 
and  frontal),  hemorrhoids,  decayed  teeth,  digestive  disturbances, 
and  toxic  disturbances.  The  reflex  headaches  are  due  to  irrita- 
tion of  the  nerve  centers,  and  owe  their  presence  to  circulatory 
changes  in  the  brain. 

Under  reflex  headaches  it  is  also  proper  to  consider  headaches 
which  follow  intense  irritation  of  the  organs  of  special  sense,  for 
in  many  cases  headaches  follow  a  loud  noise,  exposure  to  an  in- 
tense light,  or  a  strong  and  disagreeable  odor.  These  headaches 
are  probably  reflexes  from  the  centers  affected  to  the  centers  of 
the  cutaneous  area  in  which  the  pain  is  felt. 

Hunger  headaches  are  due  to  a  lack  of  nutrition  in  the  brain 
cells  of  the  cerebral  cortex  (in  reality  toxic  headaches).  This 
condition  is  common  in  children. 

Headaches  which  follow  excessive  venery  are  probably  due 
to  cerebral  fatigue.  To  the  same  class  belongs  the  headache 
which  follows  loss  of  sleep,  such  as  occurs  in  those  who  have  been 


278 


REGIONAL   PAINS 


up  all  night,  or  in  those  who  have  missed  an  accustomed  mid- 
day nap. 

Disturbance  of  the  brain  substance  from  worry,  etc.,  may 
cause  some  change  in  the  molecular  structure  of  the  cortex, 
and  this,  in  turn,  produces  reflex  circulatory  disturbances, 
which  may  be  the  cause  of  pain.  Associated  symptoms  of  such  a 
state,  according  to  Drein,  are  malaise,  irritability,  digestive  and 
visceral  disturbances,  nausea,  confusion  of  ideas,  and  vertigo. 


Hysteria 

Carious  teeth 

Cerebral  arteriosclerosis 


Ear  disease 

(Furunculosis) 
Parotiditis 

Pharyngeal  diaeaae 

Tonsil  disease 

ronsillar  gland  is  at  this  point 

Maximum  pain  in  angina 
pectoris 


Fig.  64. — Locations  of  the  Principal  Headaches. 


Neuralgia  of  the  cortex  is  also  given  as  a  cause  of  headache. 
As  neuralgia  means  but  an  increased  irritability  of  the  sensory 
centers,  or  of  the  nerves  conducting  sensation  and  is  used  more 
to  define  a  functional  lesion,  it  may  not  be  entirely  proper  to 
apply  the  term  to  the  condition  in  which  pain  is  produced  by  a 
cortical  organic  irritative  lesion  leading  to  lessened  resistance 
and  increased  susceptibility.  We  find  an  increased  suscepti- 
bility of  this  kind  in  neurasthenia  and  allied  depressive  states, 
in    which    a    bright    light,    a    thunderstorm,    etc.,    will    produce 


THE   HEAD 


279 


headache.  It  is  also  held  that  there  is  a  headache  caused  by  an 
irritation  of  the  cerebral  cortex  by  toxic  materials,  such  as  was 
claimed  by  the  older  writers   (Boerhaave,  Van  Sweten)  to  occur 


Referred  pain  from  vertebra 

Caries 
Tumors 

Arthritis  deformans 
Meninges — meningitis 
Malignant  disease  (sarcoma)  of 
vertebra 
I  Aneurysm  of  vertebral  artery 
Elevation    of    the    intracranial 
pressure,  as  in: 

(1)  Hydrocephalus 

(2)  Nephritis 


Fig.  65. — Figure  Illustrating  the  Locations  of  the  Principal  Head- 
aches. 

The  back  of  the  head  and  the  nape  of  the  neck  are  supplied  by:  1.  Occipitahs 
major,  which  lies  toward  the  mid-line  and  which  is  a  branch  of  the  2d 
cervical  nerve  which  passes  through  between  the  axis  and  atlas,  and 
may  be  easily  injured,  owing  to  the  great  mobility  of  these  parts;  it  is 
also  affected  in  tuberculosis  of  this  region;  therefore  pain  would  be  felt 
in  the  occipitalis  major  area  of  distribution  in  disease  of  either  the  atlas 
or  axis.  2.  Occipitahs  minor,  which  lies  more  laterally.  3.  Auricularis 
magnus,  which  supplies  the  posterior  Surface  of  the  ear.  Occipital  head- 
ache pain  begins  at  the  junction  of  the  skull  and  the  cranium  and  runs 
up  the  back  of  the  head  to  the  vortex  or  laterally  to  the  back  of  the  ears. 


in  rheumatic  headaches.  These  headaches  are  of  a  mobile  char- 
acter, and  occur  at  various  parts  of  the  cranium,  being  especially 
common  in  the  occipital  and  frontal  regions.  The  pain  seems  to 
be  well  within  the  skull,  and  pressure  on  the  surface  does  not 
modify  its  character  as  is  the  case  in  rheumatism  of  the  scalp. 


280 


REGIONAL    PAINS 


The  muscles  of  the  neck  are  more  or  less  rigid,  and  the  movement 
of  the  head  is  painful.     Conditions  of  cold  and  dampness  influence 


Fig.  66. — Occipital  Headache. 

the  head  symptoms  the  same  as  they  influence  rheumatic  affec- 
tions of  the  joints. 


Fig.  67. — Frontotemi'ural  Headache. 

In  many  painful  lesions  of  the  brain   the   skin  over   a  cer- 
tain  area   of  the    head   is  very   sensitive   to   pressure.      This   is 


THE   HEAD 


281 


thoiiglit  to  be  due  to  the  relations  existing  between  the  nerve 
filaments  of  the  meninges  and  those  of  the  scalp  overlying  the 
affected  area. 

Diseases  producing  reflex  headaches  are :  brain  abscess, 
chronic  appendicitis,  gall  stones,  chronic  gastritis,  intestinal  de- 
rangements, etc.  The  menstrual  period  also  is  often  ushered  in 
with  a  severe  headache. 

In  the  accompanying  drawings  the  locations  of  the  principal 
headaches  are  given ;  and  since  these  locations  can  be  illustrated 
much  better  than  described,  the  latter  has  been  thought  unnec- 
essary.    (Figs.  61,  62,  63,  64,  65.) 


Fig.  68. — Temporal  Headache. 

In  almost  every  case  of  headache  the  patient  tries  to  ease  the 
pain  by  making  pressure  on  the  head.  This  is  illustrated  in 
figures  66,  67,  68. 

Diagnosis  of  Headache.  — The  following  may  be  of  use  in  the 
diagnosis  of  headaches : 

Origin. — First,  ascertain  if  the  headache  is  of  recent  or  of 
remote  origin.     If  it  is  of  recent  origin,  examine  for : 

(1)  Acute  infectious  diseases  in  which  the  pain  may  be  the 
result  of  a  direct  action  on  the  pain-conducting  trigeminal  tract, 


282  REGIONAL   PAINS 

or  due  to  an  elevation  of  the  intracranial  pressure.     The  most 
common  infectious  diseases  causing  head  pain  are  influenza,  ty- 
phoid fever,  tonsillitis,  and  the  acute  exanthemata  (measles  and 
scarlet  fever). 
.    (2)      Injury   (traumatism). 

(3)  Toxemia:  (a)  endogenous  (hepatic  torpor);  (b)  exogen- 
ous (constipation,  drugs). 

(4)  Intracranial  lesions  (meningitis),  either  tuberculous  or 
septic.  In  either  case,  the  characteristics  are  a  constant  pain,  in- 
terrupted by  paroxysms  of  greater  severity,  and  increased  by 
movement  or  on  the  taking  of  food  or  drink.  Vomiting  and 
nausea  occur  in  the  absence  of  the  ingestion  of  food.  In  some 
cases,  when  the  intracranial  pressure  becomes  high,  optic  neuritis 
follows.  Tuberculous  meningeal  headaches,  as  a  rule,  are  frontal 
or  occipital  (Taylor,  632). 

Probably  the  headaches  of  all  the  acute  diseases  are  due  to 
toxic  causes.  While  headache  is  a  common  accompaniment  of  all 
acute  infectious  diseases,  yet  some,  as  pneumonia,  may  be  entirely 
free  of  headache  throughout  their  whole  course. 

Remote  Origin. — If  the  headache  has  been  of  a  chronic  type, 
a  knowledge  of  the  relative  frequency  of  the  different  forms  of 
chronic  headache  may  aid  greatly  in  forming  a  diagnosis.  Accord- 
ing to  Edinger,  two-fifths  of  the  chronic  headaches  are  of  the  in- 
durative type,  two-fifths  are  of  the  migraine  type,  and  one-fifth 
consist  of  other  types.  The  majority  of  all  headaches  are  in  the 
frontal  region.  In  our  examination  of  structural  changes,  as  a 
cause  for  chronic  headache,  we  begin  an  examination  of  the  dif- 
ferent organs  in  the  following  order: 

(1)  The  eyes  produce  the  so-called  ocular  headaches.  In 
these  headaches  the  pain  is,  as  a  rule,  more  severe  on  using 
the  eyes.  Brooks  thinks  that  the  principal  eye  conditions  giv-. 
ing  rise  to  headaches  are  errors  of  refraction,  by  which  an 
excessive  amount  of  work  is  thrown  upon  the  ciliary  muscles; 
want  of  balance  between  the  external  muscles  of  the  globe;  and 
retinal  hyperesthesia,  in  which  the  retina  is  very  sensitive  to  light. 
Ocular  headaches  are  usually  located  over  the  middle  of  the  eye- 


THE    HEAD  283 

brow  and  the  pain  radiates  into  the  back  of  the  eye   ( Jessop, 
634). 

(2)  The  nose  ^  causes  a  pain  that  lies  to  the  inner  side  of, 
and  extends  higher  on  the  forehead  than  the  pain  due  to  eye  strain. 
The  nasal  conditions  causing  headache  are  stenosis  (chronic  ob- 
struction due  to  foreign  bodies,  rhinoliths,  tumors,  hypertrophy  of 
the  turbinate,  bending  of  the  septum),  vasomotor  alterations,  epi- 
staxis,  sinns  involvement.  lodid  coryza  should  also  be  thought  of, 
especially  in  those  who  are  undergoing  treatment  for  syphilis. 
The  cause  of  the  headaches  in  cases  of  nasal  obstruction  seems 
partly  at  least  to  be  due  to  the  lack  of  oxygen,  because  it  has  fre- 
quently been  found  that  patients  suffering  from  recurring  head- 
aches, or  from  neurasthenia,  are  immediately  relieved  of  the 
trouble  by  the  removal  of  some  obstruction  in  the  nose  or  sinuses. 
Turbinate  headache  is  usually  periodic,  depending  on  the  inter- 
mittent swelling  of  the  mucous  membrane  covering  the  surface  of 
the  anterior  end  of  the  turbinate.  Sinus  involvement  may 
cause  severe  pain;  for  in  one  of  Hartman's  cases  trigeminal  neu- 
ralgia, due  to  this  condition,  had  persisted  for  weeks,  the  pain 
being  so  intense  that  sleep  had  been  impossible.  The  most 
diverse  treatment  had  given  no  relief.  All  pain  vanished  im- 
mediately after  the  maxillary  sinus  was  evacuated  of  the  cheesy 
matter  with  which  it  had  been  filled.  In  other  cases  supraorbital 
neuralgia,  which  recurred  every  day  at  a  certain  hour,  was  the 
result  of  inflammation  in  the  frontal  sinus,  and  was  cured  by 
appropriate  treatment.  The  pain  may  be  due  to  the  inflamma- 
tion itself,  to  compression  from  secretions,  or  merely  to  rare- 
faction of  the  air  in  the  sinus.  The  trouble  may  not  be  due  to 
an  inflammatory  process,  but  merely  to  the  occlusion  of  the  sinus, 
by  which  communication  with  the  air  is  shut  off.  This  is  a  com- 
paratively frequent  occurrence,  and  is  liable  to  cause  distressing 
pain.  Opening  a  communication  into  the  nose  banishes  the  pain 
at  once  (Hartman).  A  particular  variety,  met  most  frequently 
by  Thompson  (488),  and  associated  with  old  fractures  of  the 
nasal  bones,  seemed  to  begin  at  the  roof  of  the  nose  and  to  pass 

*  See  page    342,    Nasal   Stenosis. 


284  REGIONAL   PAINS 

horizontally  backward  to  the  occiput.  It  was  always  aggravated 
by  prolonged  bending  forward  of  the  head,  as  in  writing,  and 
had  a  special  tendency  to  cause  incapacity  for  mental  work. 

(3)  Diseases  in  the  accessory  nasal  sinuses  are  also  causes 
for  headaches.  The  sinuses  affected  are  the  frontal,  antral,  eth- 
moidal and  sphenoidal.  Headache  due  to  disease  of  these  sinuses 
is  generally  relieved  by  the  discharge  of  pus  or  mucus  from 
the  nose.  In  these  conditions,  the  seat  of  pain  is  generally  frontal, 
although  most  authors  believe  that  it  bears  no  special  relation 
to  the  site  of  the  disease.  Lack  (623), however, holds  that  the  head- 
ache due  to  sphenoidal  sinus  involvement  is  "referred  to  the  back 
of  the  head  and  then  radiates  down  the  back  of  the  neck."  That 
due  to  the  ethmoid  is  found  in  the  frontal  region,  in  the  eyes,  and 
deep  in  the  head  behind  the  eyes;  while  that  due  to  the  antrum 
is  found  over  the  molar  bone  and  may  extend  upward  to  the 
temporal  region.  He  also  states  that  the  frontal  sinus  headache  is 
most  severe  at  the  "top  of  the  head  over  the  posterior  part  of  the 
frontal  bone."  The  original  location  of  the  pain  is  generally 
continued  throughout  the  disease. 

(4)  The  ears,  in  many  cases,  cause  head  pain.  The  prin- 
cipal causes  acting  upon  the  ears  to  produce  head  pain  are  anemia 
and  mastoid  disease. 

(5)  The  alimentary  tract  gives  rise  to  headache.  Various 
forms  of  mouth  disease,  gastrointestinal  disorders,  intestinal  para- 
sites, constipation,  dyspepsia,  and  cholelithiasis  may  be  the  cause 
of  severe  pain  in  the  head.  Dull,  generalized  headache  and  coated 
tongue  are  due  to  indigestion. 

(6)  In  kidney  lesions  the  pain  is  felt  particularly  at  the 
back  of  the  head,  and  radiates  down  the  neck.  Torticollis  and 
disease  of  the  vertebrae  should  be  eliminated. 

(7)  Brain  tumors  and  abscesses  are  common  causes  of 
headache.  The  location  of  the  pain  often  corresponds  with  the 
site  of  the  tumor.  Sometimes  the  pain  is  increased  by  pressure. 
It  may  not  be  constant,  but  generally  it  is  periodic.  Cerebellar 
tumors  commonly  are  on  the  side  opposite  to  that  in  which  the 
headache  is  found.     Tumor  headaches  are  caused  by  the  pressure 


THE   HEAD  285 

of  the  growth  obstructing  the  vena  magna  galeni  or  the  aqueduct 
of  Sylvius  (Schmidt),  both  conditions  lead  to  increased  intra- 
ventricular pressure.  The  location  of  a  brain  tumor  cannot  be 
diagnosed  from  the  situation  of  the  headache.  For  a  fuller  con- 
sideration of  these  headaches,  see  page  182. 

(8)  Psychical  strain  will  produce  severe  headache.  This  is 
likely  to  be  frontal,  and  generally  is  the  result  of  long-continued 
worry  or  severe  mental  effort.  A  headache  of  this  character  is 
Influenced  most  by  psychic  states.  Mental  effort  gi-eatly  in- 
creases it.  In  this  it  differs  from  a  headache  due  to  increased 
intracranial  pressure,  which  is  most  influenced  by  mechanical 
factors,  such  as  change  in  position  of  the  head  and  body,  bleeding 
from  the  nose,  or  blood-letting. 

(9)  Between  lead  poisoning  and  gout,  and  the  uric  acid 
diathesis,  probably  there  is  a  close  relationship.  All  these  pro- 
duce headache. 

(10)  The  headache  of  anemia  is  due  to  a  hydremic  hydro- 
cephalus, with  a  consequent  rise  in  the  intracranial  blood  pressure. 
Elevating  the  head  often  causes  great  relief. 

(11)  Cerebral  arteritis:  Of  the  general  symptoms  of  cere- 
bral arteriosclerosis,  headache  stands  first.  It  is  usually  dull,  not 
throbbing,  and  quite  often  is  described  as  a  feeling  as  though  a 
tight  band  were  compressing  the  head.  It  occurs  most  frequently 
in  the  morning,  after  walking  about,  and  diminishes  as  the  day 
advances,  except  in  syphilis,  in  which  it  is  usually  most  severe 
at  night.  A  peculiarity  worth  noting  in  this  class  of  patients  is 
that,  even  though  arteriosclerosis  is  present,  there  is  also  a  lowered 
blood  pressure,  which  is  probably  the  result  of  secondary  cardiac 
weakness.  It  averages  from  110  to  130  mm.  Hg.  The  causa- 
tion of  the  headache  can  be  explained  from  the  fact  that,  since 
the  cerebral  arteries  are  terminal  arteries,  a  sclerosis  of  the  coats 
would  cause  a  narrowing  of  the  lumen,  which  would  produce  an 
anemia  of  the  cortex  of  the  brain.  The  anemia,  of  course,  would 
then  produce  headache  and  giddiness.  Why  there  should  be  a 
systemic  lowered  blood  pressure,  is  difficult  to  explain. 

The  patient  should  also  be  questioned  in  regard  to  the  con 


286  REGIONAL   PAINS 

stancy  of  the  lieadache ;  that  is,  whether  it  is  intermittent  or  per- 
sistent, and  then,  if  it  is  intermittent,  whether  the  intermittence 
is  regular  (periodic)  or  irregular. 

Intermittent  Headaches  (Periodic  Type). — According  to 
Edinger,  two-fifths  of  all  headaches  from  wliieh  patients  suffer  are 
of  the  periodic  type.  The  most  important,  as  well  as  the  best 
known,  of  the  periodic  headaches  is  migraine.  Two  types  of 
migraine  are  recognized : 

(1)  The  reflex  migraine,  which  begins  later  in  life  than 
does  the  true  variety,  and  is  dependent  principally  upon  a  non- 
inherited,  peripheral  cause.  In  this  class  of  cases  there  is  no  evi- 
dence of  a  neurosis  in  the  family,  and  the  headache  becomes 
worse  instead  of  better  in  middle  life.  A  preliminary  visual 
spectrum  is  absent.  The  headaches  are  warded  off  by  purgatives 
and  laxatives,  while,  in  contrast,  the  true  migraine  headaches  are 
not  influenced  by  such  means,  but  are  lessened  by  phenacetin. 
The  principal  causes  of  reflex  migraine  are  eye  strain,  constipa- 
tion, and  intestinal  toxemia.  These  headaches  may  also  be  pro- 
duced by  peri2:)heral  factors,  as  injury  to  the  nerve  following  a 
blow  on  the  head,  or  a  fall,  in  which  the  third  nerve  has  been 
damaged.  In  some  cases,  after  recovery  from  a  head  injury,  a 
patch  of  meningeal  thickening  may  remain  and  cause  head  pain. 
In  this  form  there  is  sometimes  a  recurrent  third  nerve  paralysis, 
and  the  patient  is  attacked  by  severe  headache  lasting  a  day  or 
two.  The  third  nerve  recovers  its  functions  in  the  course  of  some 
weeks,     A  visual  spectrum  rarely  develops. 

(2)  In  the  hereditary  form  of  migraine  there  is  a  distinct 
history  of  the  heredity.  Generally  some  member  of  the  family 
has  been  a  sufferer  from  this  condition.  If  none  has  been  affected 
with  headaches  often  there  is  one  member  who  is  subject  to  attacks 
of  epilepsy,  neuralgia,  etc.  Migraine  appears  in  adult  life  and 
may  be  caused  by  prolonged  debilitating  diseases.  An  individual 
attack  is  frequently  induced  by  the  menses,  which  it  may  precede 
or  follow,  a  prolonged  railway  journey,  a  close,  badly  ventilated 
room,  great  heat,  emotion  (as  anger),  excitement,  the  use  of  a 
small  quantity  of  alcohol  or  tobacco,  unusually  early  awakening, 


THE   HEAD  '       287 

omission  of  a  meal,  or  strain  of  the  eyes,  especially  if  the  strain  is 
on  the  ciliary  muscles. 

Migraine  gives  rise  to  a  throbbing  j^dif^-  It  begins  with  dis- 
comfort and  gradually  increases  until  it  is  agonizing  in  its 
severity.  It  generally  begins  over  one  eye  and  then  spreads  to 
the  forehead  and  the  side  of  the  head.  It  is  increased  by  bending 
over,  by  noises,  or  by  any  sudden  exertion.  Eating  may  also  in- 
crease it.  Drinking  alcoholic  beverages  and  smoking  make  it 
worse.  Strong  light  augments  the  distress.  Because  of  all  these, 
the  patient  generally  seeks  a  quiet  and  dark  room  and  lies  very 
still. 

A  symptom  almost  pathognomonic  of  migraine  is  scintillating 
scotoma,  which  appears  before  the  pain  commences.  The  scotomata 
appear  as  floating  dark  spots  in  the  visual  field,  the  borders  of 
which  are  often  serrated  and  illuminated.  Some  see  only  the 
illuminated  edges  of  the  spots,  and  may  complain  of  dulness  of 
vision. 

The  individual  paroxysm  of  pain  may  last  for  a  few  minutes, 
or  an  hour,  while  the  period  of  attack  may  last  for  a  few  hours  or 
all  day.  The  premonitory  symptoms  of  migraue  are  lassitude, 
irritability  and  incapacity  for  arduous  work.  They  often  appear 
in  the  evening  before  the  attack,  while  on  the  morning  of  the 
attack  the  patient  complains  of  numbness  in  the  head  and  an  ex- 
tremely tired  feeling.  The  pain  begins  gradually,  and  is  felt 
deep  in  the  head,  with  a  sensation  as  though  the  head  were  split- 
ting. There  are  also  a  burning  and  a  sense  of  pressure  in  and 
behind  the  eyes.  The  pain,  as  a  rule,  is  unilateral.  It  is  asso- 
ciated with  a  feeling  of  distress.  Loss  of  appetite  and  cold  feet 
are  often  present.  The  physical  signs  associated  with  migraine 
are:  a  generally  pale  face  (though  it  may  be  red),  injected  con- 
junctivae, narrowed  palpebral  fissure  and  contracted  pupils.  The 
contraction  of  the  pupils  is  an  important  differential  sign,  as  in 
all  other  conditions  where  severe  pain  is  present  the  pupils  are 
dilated.  Vomiting,  as  a  rule,  finally  occurs,  and  when  it  does  the 
headache  ceases. 

True  migraine  is  the  most  important  and  commonest  of  the 


288  REGIONAL    PAINS 

forms  of  periodic  lieadache.  The  severe  pain  in  the  head  seems 
to  be  due  to  an  increase  of  the  intracranial  pressure.  The  hemian- 
opsia, the  dimness  of  A'ision,  the  numbness  in  the  tongue,  cheek  or 
arm,  and  the  temporary  aphasia  are  all  suggestive  of  sudden  ar- 
terial constriction  in  the  cortex.-^  Vomiting  is  also  a  most  char- 
acteristic sign  of  elevation  of  intracranial  pressure. 

Brunton  is  also  in  accord  with  the  arterial  constrictive  hypoth- 
esis, for  he  claims  that  the  pain  of  migraine  is  due  to  a  con- 
traction of  the  peripheral  part  of  the  temporal  artery,  and  a  dila- 
tation of  the  proximal  part.  He  noticed  that  in  every  case  of 
migraine  the  carotid  was  widely  dilated,  while  in  many  cases  the 
peripheral  part  of  the  temporal  artery  seemed  to  be  contracted, 
and  in  other  cases  dilated;  but,  in  every  case,  the  little  branch 
which  turns  upward  on  the  forehead  was  found  to  be  firmly  con- 
tracted. Pressure  upon  the  carotid  would  oftentimes  relieve  the 
pain,  which  ceased  as  long  as  the  pressure  was  maintained,  but 
returned  as  soon  as  the  pressure  was  removed.  Pressure  upon  the 
carotid  artery  of  necessity  produces  pressure  upon  the  pneumo- 
gastric  nerve,  causing  great  disturbance  to  the  respiration,  with  a 
"feeling  as  though  the  entire  chest  were  contracted,  or  as  though 
someone  were  pressing  down  with  a  giant's  weight  upon  it." 
Therefore,  pressure  on  the  artery,  because  of  these  symptoms, 
cannot  be  long  continued. 

These  views  of  Brunton  are  in  accord  with  the  opinions  of 
Edinger  and  Harris,  who  also  think  that  migraine  is  accompanied 
and  conditioned  by  a  contraction  of  the  peripheral  arteries.  While 
as  yet  no  vasoconstrictor  nerves  can  be  found  in  the  brain,  the 
pale  eyegrounds,  the  general  vascular  spasm  which  causes  dizzi- 
ness, and  also  the  occasional  disturbances  of  speech  all  seem  to 
confirm  the  anemic  hypothesis.  Another  idea  of  the  cause  is  ex- 
pressed by  Jelliffe,  who  follows  Spitzner  in  believing  that  migraine 
is  due  to  an  absolute  or  relative  stenosis  of  the  foramen  of  Monroe. 
According  to  the  same  authority,  an  occasional  hyperemia  of  the 

1  Although  cerebral  arterial  constriction  has  been  given  by  many 
authors  as  a  cause  of  increased  intracranial  pressure,  it  seems  to  me  that 
the  arterial  constriction  does  not  cause  a  congestion  but  an  anemia,  and  that 
phe  primary  condition  is  not  an  arterial  constriction  but  a  dilatation. 


THE   HEAD  289 

brain  leads  to  a  hyperemia  of  the  choroid  plexus.  This,  in  turn, 
causes  a  greater  narrowing  of  the  foramen,  and  an  increase  of 
tension  in  one  or  both  ventricles.  This  causes  a  still  further  con- 
gestion of  both  choroid  plexuses,  and  increases  the  narrowing. 
The  vicious  circle  continues  until  the  pressure  is  relieved  or  the 
tension  is  reduced  by  a  shock  reaction,  such  as  occurs  in  vomiting, 
or  in  the  use  of  the  vasodilators. 

According  to  Levi  and  Rothschild,  there  is  also  a  migraine 
due  to  a  diminished  secretion  of  thjroidin.  These  doctors  have 
succeeded  in  ameliorating  seven  cases  of  migraine  with  thyroidin ; 
and  in  their  description  of  thyroid  migraine  they  say  that  "the 
existence  of  this  affection  is  evident  by  the  migraine  being  re- 
lieved with  thyroidin ;  by  the  hypothyroid  signs  we  meet  in  people 
suffering  from  migraine ;  by  the  autotherapy  of  preg-nancy ;  by  the 
influence  of  female  sexual  life  (puberty)  on  the  appearance  of 
the  affection;  by  the  paroxysmal  crises  (during  menstruation)  of 
the  affection;  and  by  their  cessation  at  the  menopause.  Thyroid 
migraine  symptoms  do  not  differ  from  those  of  common  migraine. 
It  is  either  precocious  or  tardy,  hereditary  or  acquired ;  unilateral 
or  bilateral;  syndromic  or  symptomatic.  It  may  last  only  some 
hours  or  days,  but  is  always  paroxysmic." 

"  Other   causes   of   periodic    headaches   are,   malaria,    syphilis, 
habit,  hysteria,  lymphatism. 

If  the  periodic  headache  is  due  to  malaria,  there  is  some 
malarial  history.  Chills,  fevers  and  sweats  occur,  an  enlarged 
spleen  can  be  palpated,  and  plasmodia  can  be  found  in  the  blood. 

In  headache  due  to  syphilis,  the  pain,  as  a  rule,  occurs  at 
night,  and  is  usual  after  excitement. 

Hahit  Headache.— If  a  periodic  headache  occurs  at  the  same 
time  of  the  day  or  week,  examine  for  some  disease  or  habit,  in 
the  history  of  the  patient,  which  would  be  likely  to  bring  on 
headache,  or  to  act  as  a  predisjDosing  factor  in  its  production. 
Inquire  into  the  manner  of  work,  sleeping,  eating,  etc.,  of  the 
patient. 

Hysterical  headache  may  be  present,  in  which  case  there  are 
other  signs  of  the  hysterical  involvement. 


290  REGIONAL   PAINS 

Ross  speaks  of  a  form  of  headache  which  he  calls  the  lymphatic 
headache.    He  describes  it  as  having  the  following  characteristics : 

(1)  It  is  present,  and  most  severe,  on  walking,  and  tends  to 
lessen  in  intensity,  or  altogether  disappear,  in  from  one  to  six 
hours. 

(2)  It  usually  manifests  itself  as  a  dull,  heavy  ache,  or  as 
a  frontal  or  temporal  throbbing.  Less  frequently  it  is  occipital, 
vertical,  or  unilateral.     Infrequently,  also,  it  is  neuralgic. 

(3)  In  its  typical  form  it  is  exceedingly  chronic,  often  of 
several  years'  duration,  and  most  intractable.  It  is  the  common, 
occasional  headache  to  which  most  people  are  subject. 

(4)  It  is  associated  with  a  deficient  coagulability  of  the 
blood. 

The  posliDxs  assumed  by  patients  suffering  from  the  different 
varieties  of  headaches  are  illustrated  in  Figs.  GG,  G7  and  68. 
In  all  of  these  headaches,  the  principal  factor  sought  by  the  patient 
seems  to  be  the  application  of  pressure  over  the  painful  area. 
This,  in  nearly  all  cases,  relieves  the  pain;  so  it  is  possible  that 
in  these  headaches  the  pain  is  a  superficial  pressure  phenomenon 
(skin,  muscles,  etc.,  of  scalp),  and  that  pressure  applied  over  the 
area  of  local  pain  removes  the  congestion  and  thus  relieves  the 
pain. 

Hyijeralgesic  zones  of  the  head,  according  to  Ilannsa  (G2b), 
frequently  occur  in  lesions  at  the  base  of  the  skull.  The  most 
common  of  these  are  the  result  of  bullet  wounds  of  the  skull, 
basilar  fractures,  and  concussion.  The  zones  may  lie  in  the  area 
of  distribution  of  the  second  to  fifth  cervical  segments — or  in  the 
distribution  area  of  the  trigeminus.  Ilannsa,  as  well  as  Wilms, 
Milner,  Vorschiitz,  Clairmont,  etc.,  claim  that  the  cause  of  these 
zones  is  a  lesion  of  the  sympathetic. 

In  this  connection,  also.  Head  has  observed  that  most  of  the 
viscera  cause  pain  which  is  referred  both  to  an  area  in  the  body 
and,  in  many  cases,  also,  to  one  in  the  head,  where  it  is  expressed 
as  tenderness.  Head  found  that  these  areas  were  associated  with 
certain  visceral  areas  of  tenderness.  These  associations  are  given 
by  Head  in  the  table  on  page  295  (Head,  Brain,  1894,  p.  4G4). 


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291 


TeiDporal 

a.  Glaucoma 

b.  Caries  of  upper  teeth 

c.  Gastric  disturbances  asso- 

ciated with  nausea  and 
vomiting 


Midorbital 
Hypermetropia 


Rostronasal 


Nasolabial 

a.  Disease      of      respiratory 

part  of  nose 

b.  Caries  of  teeth 

Mandibular 

Disease  of  last  two  molars  of 
upper  jaw 

Superior  laryngeal 

a.  Disease  of  wisdom  teeth  of 

lower  jaw 

b.  Disease  of  posterior  part 

of  dorsum  of  tongue 


Parietal 

Diseases  of  the  ear 


Sternomastoid  area 

Diseases  of  the  chest,  as  tur 
berculosis  of  the  lung,  etc. 


Fig.  70. — Lateral  View  of  Head's  Zones. 
Solid  black  areas  show  points  of  maximum  tenderness. 


292 


THE   HEAD 


293 


It  seems  that  ''all  the  thoracic  and  abdominal  viscera,  which 
refer  pain  into  the  dorsal  areas  of  the  scalp,  are  supplied  by 
what  might  be  termed  the  vago-glosso-pharyngeal  ner\'e — this  con- 
sisting of  the  vagus  and  the  glosso-pharyngeal  nerves.     These  two 


y     ,  •     1  j  Disease  of  posterior  portion  of  the  eye 
'(  Elevation  of  tension  in  the  middle  ear 


Occipital 

a.  Lesion  of 
posterior 
part  of 
dorsum  of 
tongue 

b.  Referred 
pain  from 
the  abdo- 
men 

Hyoid 

a.  Disease  of 
tonsils 

b.  Disease  of 
teeth 

c.  Disease  of 
tongue 

Sternonuchal 
Diseases      of 
organs      of 
thorax,  ab- 
domen, etc. 


Frontotemporal 

a.  Reference 
pain  from 
t  h  o  rac  i  c 
viscera 

b.  Iritis 

c.  Glaucoma 
Fronto-nasal 

a.  Substance 
of  cornea 

b.  Anterior 
chamber  of 
eye 

c.  L'pper  o£ 
nose 

d.  Incisor 
teeth  of  up- 
per jaw 

Mental 

a.  Disease  of 
anterior 
part  of 
tongue 

b.  Disease  of 
incisor  and 
canine 
teeth  of 
lower  jaw 

Superior  laryngeal 

a.  Disease  of 
wisdom 
teeth  of 
lower  jaw 

b.  Disease  of 
posterior 
part  of  dor- 
sum of  the 
tongue 


Fig.  71. — Lateral  View  of  Head's  Zones. 
(From  Head.) 
nerves  represent  the  visceral  branches  of  a  set  of  nerves  whose 
somatic  sensory  roots  are  to  be  found  in  the  sensory  portion  of 
the  fifth  nerve.  Therefore,  it  is  possible  to  understand  how  the 
impulses  passing  up  the  vagus  may  be  referred  to  the  distribution 
area  of  the  fifth  nerve. 


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294 


Area  on  Body 

Associated  Area  on 
Scalp 

Organs  in  Particular  Relation 
with  Those  Areas 

Cervical  3. 

Frontonasal. 

< 

[Apices  of  lung. 
1  Liver. 
1  Stomach. 
[  Aortic  orifices. 

Cervical  4. 

Frontonasal. 

Lung. 

Dorsal    2. 

Midorbital. 

fLung. 

<  Heart  (ventricles). 

[  Ascending  arch  of  aorta. 

Dorsal    3. 

Midorbital. 

f  Lung. 

i  Heart  (ventricles). 

[  Arch  of  aorta. 

Dorsal    4. 

Doubtful. 

Lung. 

Dorsal    5. 

Frontotemporal. 

/  Lung. 

\  Heart  (occasionally). 

Dorsal    6. 

Frontotemporal. 

f  Lower  lobes  of  lungs. 
\  Heart  (auricles). 

Dorsal    7. 

Temporal. 

f  Bases  of  lungs. 
\  Heart  (auricles). 
[  Stomach  (cardiac). 

Dorsal    8. 

Vertical. 

f  Stomach. 

\  Liver. 

[  Upper  part  of  small  intestine. 

Dorsal    9. 

Parietal. 

f  Stomach  (pyloric  end) . 

\  Upper  part  of  small  intestine. 

Dorsal  10. 

Occipital. 

f  Liver 
1  Intestine. 
1  Ovaries. 
[  Testes. 

Dorsal  11. 

Occipital. 

r  Intestine. 

1  Fallopian  tubes. 

1  Uterus. 

[  Bladder  (contraction). 

Dorsal  12. 

Occipital. 

f  Intestine  (colon). 
\  Uterus. 

295 


296  REGIONAL   PAINS 


PAIN   IN    THE    BACK 


This  includes  all  pains  from  the  base  of  the  skull  to  the  coccyx. 
They  may  be  the  result  of  a  lesion  of  the  structural  units  of 
the  back  (skin,  muscles,  nerves,  or  bone),  or  may  be  referred 
from  other  regions.  The  skin  of  the  back  is  hypersensitive  in 
many  of  the  diseases  of  the  internal  organs — in  these  the  zones  of 
Head  are,  as  a  rule,  pronounced — and  in  all  cases  should  be 
sought.  In  many  of  the  infectious  diseases  the  skin  is  also  very 
sensitive,  both  to  touch  and  to  pricking. 

In  examining  the  back  for  the  presence  of  pain  phenomena  first 
try  light  touch  and  pin-point  pressure.  If  these  are  not  painful, 
make  deep  pressure,  or  gTasp  the  muscles  between  the  fingers ; 
shouid  the  patient  now  complain  of  pain,  we  may  conclude  that  it 
is  the  muscles  which  are  affected.  The  muscles  most  frequently 
affected  are  in  the  neck,  and  the  most  common  afi^ection  is  rheuma- 
tism, which  in  the  neck  produces  torticollis,  and  in  the  small  of 
the  back  lumbago.  These  rheumatic  affections  are  characterized  by 
a  sudden  onset,  the  great  pressure  sensibility  over  definite  muscular 
areas,  the  increase  of  the  pain  on  movement,  and  the  favorable 
influence  through  massage,  faradization  and  heat.  In  many  cases, 
also,  the  pain  and  tenderness  seem  to  be  inilncneed  by  the  weather, 
becoming  much  worse  on  rainy  days.  Only  by  their  course  do 
the  chronic  rheumatisms  of  the  back  muscles  differentiate  them- 
selves from  acute  forms.  Johnson  (Brit.  Med.  Jour.,  1881, 
p.  221)  mentions  back  pains,  which  lasted  a  long  time,  and  which 
appeared  on  bending  forward.  They  were  double-sided,  and  only 
unilateral  if  the  vertebrae  were  held  crooked.  These  pains  were 
worse  after  their  onset,  and  diminished  after  a  little  movement. 
I  have  observed  a  similar  case  in  a  colleague.  In  this  instance, 
however,  not  the  muscular  but  the  tendinous  structure  was  dis- 
eased. The  colleague  complained  of  back  pain,  which  would  ap- 
pear at  certain  parts  of  the  vertebral  column,  upon  motion  or 
fixation ;  for  instance,  it  would  appear  if  he  stepped  from  the 
pavement  incautiously,  and  upon  strong  pressure.  Examination 
showed,  in  this  otherwise  healthy  individual,  a  high  degree  of 


PAIN   IN    THE    BACK 


297 


sensibility  of  the  vertebral  spines  of  the  two  lower  thoracic  verte- 
brae. Especially  sensitive  were  the  connecting  fascial  ligaments. 
The  overlying  skin  was  also  sensitive.  Deformity  was  not  pres- 
ent, and  sudden  pressure  over  the  vertebrae  was  not  especially 
painful.  There  was,  therefore,  no  reason  to  think  of  a  destruc- 
tive process  in  the  bodies  of  the  vertebrae.  I  learned  that  the  col- 
league had  worked  with  a  microscope,  in  a  somewhat  uncomfort- 
able position,  several  hours  daily  for  many  weeks,  the  microscope 
being  placed  so  low  that  he  had  to  work  with  his  back  very  much 
bent.  After  working  with  the  instrument  in  a  better  position,  the 
pain  disappeared  in  a  short  time  without  further  therapy. 

Since  lumbago  is  so  frequently  confused  with  that  of  neuras- 
thenia the  following  table  of  diagnostic  difference  is  appended. 


Lumbago 

Neurasthenia 

Pain  located. 

In  the  region  of  the  lower 
lumbar   vertebra  and 
spreads  out  sideward. 

In  the  sacral  region  and 
spreads  upward. 

Method  of  onset. 

Sudden. 

Very  gradual. 

Influence  of  motion. 

Increases  pain. 

No  action  on  the  pain. 

Points  of  tenderness. 

Pressure    on    increases    the 
pain  or  also  produces  it. 

No  pressure  points. 

Psychical  influence. 

Mental  states  have  no  in- 
fluence. 

Is  influenced  greatly  by  men- 
tal states,  irritation  (psy- 
chical) increases  the  pain, 
diversion  reduces  the  pain. 

Vertebral  column. 

Often   some   change   or   de- 
formity   present,    such   as 
scoliosis:  this  can  be  dif- 
ferentiated  from   other 
forms  of  scoliosis  by  hav- 
ing the  patient  lie  on  the 
affected  side,  in    a  sharp 
angle,   when  the  scoliosis 
disappears. 

No  change  or  deformity. 

Myalgia,  due  to  toxemia,  is  nicely  illustrated  in  those  infec- 
tious diseases  in  which  backache  is  one  of  the  most  prominent 
symptoms.  In  small-pox  the  pain  in  the  back  is  so  severe  that  the 
patient,  in  many  cases,  is  in  the  greatest  distress.  The  nature  of 
this  pain,  however,  does  not  long  remain  in  doubt,  for  the  presence 


298 


REGIONAL   PAINS 


of  the  eruption  soon  clarifies  tlie  situation.  In  the  so-called  break- 
bone  fever,  of  the  Southern  States,  it  is  also  most  severe.  Among 
the  other  infectious  diseases  in  which  backache  is  a  prominent 
symptom  are  relapsing  fever,  influenza,  tonsillitis,  typhoid  fever 
and  diphtheria. 


■Rheu.m&ti5m  ■ 

Strain* _ 

Carious  Sp\T\e- 
FractuTe  Spvne-t^^ 
Tendalou.s  Abd^&*- 
Disease  0/  -i*-*. 
Pelvic  orjaiT^ 

Sa-cro-Iii  ac-7-i^ 
DiSe^&e      ^"^ 

/ 


EiG.  73. — Figure  Showing  the  Modifications  of  Pain  in  the  Lumbar 

Region  by  Change  of  Position. 
The  arrows  indicate  the  direction  of  movement  and  +  indicates  increase 

of  pain,  while  —  indicates  decrease  of  pain  in  the  diseases  mentioned 

when  the  motion  is  made  as  indicated. 

In  myalgia  from  sprain  some  history  of  injury  is  usually 
obtainable,  and  in  some  cases  evidences  of  traumatism  are  present. 
In  myalgia  due  to  fatigue  the  pain  is  more  of  an  aching  character. 
Sitting  upright  or  standing  increases  the  pain.  Ease  may  be 
obtained,  as  a  rule,  by  reclining.  This  condition  is  frequently 
associated  with  neurasthenia,  anemia  and  depressed  mental  or 
physical  states.  Such  a  fatigued  state  is  frequently  experienced 
by  dentists,  mechanics,  barbers,  surgeons,  or  comes  on  after  cer- 
tain forms  of  exercise,  such  as  rowing.     Pain  may  also  be  due  to 


PAIN    IN    THE   BACK  299 

inflammation  in  the  subcutaneous  tissues,  as  in  perinepliritic  ab- 
scess and  inflammation  of  the  retroperitoneal  glands. 

In  the  neck,  the  stemomastoid  muscle;  either  as  a  result  of 
changes  in  its  substance  (result  of  toxic  irritations),  or  as  a  re- 
flex from  other  adjacent  structures  (neck  glands,  Ludwig's  angina, 
vertebral,  or  local  lesions),  or  from  neurotic  influences  (either 
congenital  or  acquired,  acute,  or  chronic),  becomes  so  sensitive 
that  it  remains  in  a  state  either  of  tonic  or  clonic  contractions. 
When  the  contractions  are  chronic  they  abate  gradually  but 
quickly  reappear  on  the  least  irritation  or  attempt  at  movement. 
This  condition  is  termed  torticollis.  For  a  fuller  description  of 
this  the  reader  is  referred  to  special  works  on  the  subject. 

After  a  consideration  of  the  muscles  as  causative  factors  of 
the  back  pain  the  vertebra  and  joints  should  next  be  considered. 

Vertehral  diseases,  as  tuberculous  caries  (when  inflammation 
is  acute),  cause  pain,  elicited  either  by  sharp  spinal  shocks  made 
by  forcibly  pushing  the  head  downward,  or  by  having  the  patient 
stand  with  feet  together  and  then,  after  elevating  himself  on  his 
toes,  bring  the  heels  down  to  the  ground  with  considerable  force. 
When  vertebral  disease  is  present,  pain  will  usually  be  felt  in 
the  diseased  area.  Involvement  of  the  third  to  the  fifth  vertebra 
generally  gives  rise  to  more  pain  on  bending  forward  or  back- 
ward than  does  involvement  of  other  vertebrae,  because  it  is  at  this 
level  that  flexion  and  extension  of  the  spine  most  frequently  occur 
(Cooper,  807). 

Leukemia  with  vertebral  myeloma  may  also  give  rise  to  back 
pain,  likewise,  also,  the  vertebral  metastatic  growths,  especially 
prostatic,  mammary,  or  adrenal  tumors. 

The  sacrovertebral  joints  are  also  a  frequent  cause  of  back 
pain,  whicli  may  be  either  the  result  of  inflammation,  or  of  dislo- 
cation. If  of  inflammation  the  same  signs  and  symptoms  of  in- 
flammations are  found  as  in  other  inflamed  joints  (see  page  239). 

Dislocations  also  display  here  the  same  signs  as  when  they 
occur  elsewhere.  Here,  however,  should  be  mentioned  the  sacro- 
iliac dislocation,  the  pain  of  which  causes  it  frequently  to  be  mis- 
taken for  lumbago  and  sciatica.     However,  in  this  condition  the 


300  REGIONAL   PAINS 

pain  is  in  the  sacroiliac  region,  and  extends  down  to  and  over  the 
anus.     There  is  also  rigidity  of  the  retrospinal  muscles. 

For  the  elucidation  of  this  lesion  Goldthwaite  (800)  has  for- 
mulated two  tests  (an  anterior  and  posterior  one),  which  are 
known  by  his  name.  He  describes  them  as  follows  {Annals  Surg., 
Vol.  LI,  N^o.  3,  p.  420) : 

"For  the  anterior  test,  place  the  patient  on  a  bed  with,  say, 
the  right  limb  fixed  on  the  bed ;  then  the  left  leg  is  lifted  from  the 
bed  without  flexing  the  knee.  If  it  does  not  go  as  high,  if  the 
extension  or  flexion  of  the  limb,  when  the  limb  is  extended,  is  not 
equal  to  that  on  the  other  side,  and  if  the  pain  is  acute,  we  suspect 
an  anterior  displacement  of  the  sacrum.  The  posterior  test  can  be 
made  by  extending  the  limb  upward,  with  the  patient  lying  on  the 
face."  The  diagnosis  between  muscular  and  ligamentous  pain  of 
the  spine  (Cooper,  802)  is  that  passive  posturing  will  cause  pain 
if  the  ligaments  are  involved,  while  if  the  muscles  are  involved, 
active  posturing  will  cause  pain. 

Reynolds  and  Lovett  (805)  also  speak  of  cases  in  which,  owing 
to  an  abnormal  stooping-forward  position,  the  center  of  gravity 
is  moved  forward,  and,  as  a  consequence,  considerable  strain  is 
thrown  upon  the  ligaments  and  back  muscles,  with  the  consequent 
production  of  pain. 

Osteomalacia  is  also  productive  of  very  severe  back  pain,  but 
the  associated  pregnancy  and  the  typical  pelvic  and  sacral  de- 
formity render  its  diagnosis  easy. 

Pain  over  the  coccyx  (the  so-called  coccydynia)  may  be  due 
to  injury  of  the  coccyx  from  a  fall,  or  from  over-distention  of 
the  inferior  pelvic  outlet  during  childbirth.  It  is  also  found  in 
hemorrhoids,  anal  fissure,  and  proctitis.  Lesions  of  the  conus 
medullaris  also  may  cause  pain  referred  to  this  region. 

Referred  pain  may  be  felt  in  the  back  and  be  present,  either 
as  a  result  of  disease  of  the  viscera,  or  of  some  more  distant  organ 
or  region.  The  viscera  lesions,  most  of  which  commonly  give 
rise  to  pain  in  the  back,  are :  the  lungs,  stomach,  intestine,  liver, 
and  gall-bladder,  kidney,  pancreas,  spleen,  and  pelvic  organs. 

Lungs. — Affections  of  the  lungs,  if  they  extend  to  the  pleura, 


PAIN   IN    THE   BACK  301 

frequently  lead  to  pains  which  are  felt  in  the  back,  especially  as 
the  patients  localize  the  pains  in  the  upper  part,  in  the  intra- 
scapular  space  and  in  the  shoulder,  if  the  area  of  disease  is  local- 
ized in  the  apex  or  in  the  upper  lobe.  The  more  frequent  cause 
for  such  a  condition  may  be  a  beginning  tuberculosis.  Pressure 
sensibility  of  the  skin  and  musculature,  in  the  above-mentioned 
region,  is  not  often  present.  Increase  of  the  pain  in  breathing, 
and  especially  in  coughing,  gives  an  indication,  and  an  exact 
examination  of  the  lungs  makes   the  cause  clear. 

Heart  and  Aorta.  • — Just  as  frequent  causes  for  back  pains  are 
affections  of  the  heart  or  of  the  aorta.  Here  the  pain  occurs  not 
only  in  the  back,  but  also  may  be  found  as  radiating  pain  in  the 
arm,  especially  in  the  left  arm  and  in  the  left  shoulder.  A  fre- 
quent complaint  of  such  patients  is  a  sensation  of  constriction  of 
the  thorax,  as  though  it  were  being  pressed  in  a  vise ;  but  in  this 
case  the  hand  of  the  corresponding  part  of  the  back,  or  the  shoul- 
der and  the  left  arm,  are  oversensitive.  It  will  not  be  hard  to 
differentiate  these  varieties  of  pain  from  those  which  are  caused 
by  disease  of  the  spinal  cord  or  of  the  dura.  The  circumstances 
that  heart  pains  almost  always  occur  in  paroxysms,  and  that  these 
attacks,  in  the  first  place,  are  called  forth  through  bodily  exer- 
tion, psychical  irritation,  etc.,  indicate  their  origin  in  the  heart. 
An  exact  examination  discovers  changes  in  the  aorta  and  the  car- 
diac muscle.  Absence  of  signs  of  a  spinal  cord  disease  completes 
the  finding. 

Stomach. — With  the  referred  pains  of  gastrointestinal  visceral 
disease  are  associated  the  hypersensibility  of  the  skin  and  muscu- 
lature of  the  painful  region,  and  of  the  corresponding  part  of  the 
vertebral  column,  on  the  left  side,  in  particular.  But  these  pains, 
as  they  are  especially  observed  in  ulcer  of  the  stomach  and  in 
pyloric  stenosis,  are  not  very  difiicult  to  connect  with  the  stomach, 
since  their  appearance  and  variations  in  intensity  depend  chiefly 
upon  the  taking  of  nourishment,  and  especially  upon  the  quality 
of  the  food.  It  is  unnecessary  to  say  that  the  further  examina- 
tion of  the  stomach,  in  such  a  case,  must  yield  signs  of  disease  of 
that  organ.     In  many  cases  of  total  stenosis  and  cramp  of  the 


302  REGIONAL   PAINS 

esophagus,  a  severe  pain  is  frequently  felt  in  the  shoulder  region, 
and  a  girdle  sensation  is  experienced  in  the  thorax. 

Intestines. — Pelvic  pains  are  frequently  due  to  diseased  proc- 
esses in  the  intestine.  Gas  collections  in  the  large  intestine  pro- 
duce pain  in  the  pelvis  and  in  the  flanks,  the  cause  of  which 
reveals  itself  upon  the  ajiplication  of  a  purgative.  Intestinal 
ulcers  do  not  so  frequently  cause  pelvic  pain.  On  the  contrary, 
pelvic  pains  in  carcinoma  are  an  important  diagnostic  phenomenon. 
Very  frequently  they  are  associated  with  a  radiation  in  the  limb 
and  in  the  perineum,  especially  if  the  carcinoma  is  situated  in  a 
deeper  part  of  the  colon.  Yet,  here  the  pains  almost  never  appear 
without  accompanying  symptoms.  Very  frequently  they  are  asso- 
ciated with  intestinal  symptoms,  so  that  their  recognition  causes 
no  difficulty.  Only  an  inflated  colon  can,  as  a  single  pathological 
entity,  jDroduce  dull  pain  in  the  hack,  usually  on  a  level  with  the 
kidneys.  But  here  an  exact  anamnesis,  with  the  fact  that  the  onset 
of  the  pain  dejjends  upon  the  passage  of  feces  or  of  gas,  makes  the 
diagnosis  clear. 

Liver  and  GaJl-bladder.  ■ — One  observes,  very  frequently,  in 
liver  and  gall-bladder  troubles,  jiains  in  the  shoulder,  in  the  arm, 
and  in  the  back — almost  always  on  the  right  side.  There  is  often, 
also,  an  excessive  sensibility  of  the  skin  and  of  the  correspond- 
ing musculature.  This  can  be  demonstrated  upon  picking  up 
folds  of  the  skin  and  pressing  upon  certain  places  (the  region  near 
the  tenth  to  the  twelfth  vertebral  spine).  When  the  remaining 
signs  of  gall-bladder  and  liver  disease  are  found,  the  diagnosis  is 
complete. 

Kidney. — The  spontaneous  and  pressure  sensibility  in  diseases 
of  the  kidney  (inflammation,  embolism,  congestion,  tuberculosis, 
neoplasm)  is  situated  in  the  flanks  and  pelvic  region.  Frequently, 
also,  hyperesthesia  of  the  skin  is  found.  Here  chemical  and 
microscopical  examination  of  the  urine  make  an  important  dif- 
ferentiation. In  connection  with  pus  inflammation  (perinephritic 
abscess)  pain  occurs  in  the  lumbar  region,  which  is  increased  by 
touch  and  pressure,  as  well  as  by  coughing,  sneezing  and  motion. 
In  a  similar  manner,  the  pain  of  nephritis  manifests  itself.    Radi- 


PAIN   IN   THE   BACK  303 

ation  occurs  in  the  thigh  or  is  present  in  the  form  of  an  intercostal 
neuralgia.  Patients  with  kidney  stones  complain  of  trouble  and 
pressure  in  the  lumbar  region.  If  the  pain  is  intense,  and  takes 
the  form  of  colic,  it  radiates  downward,  as  a  rule  (thigh,  testicle, 
ovary).  Frequently,  however,  it  is  found  in  the  lumbar  region 
and  in  the  loins.  The  direction  of  this  radiation,  and  the  circum- 
stance that  the  lumbar  pain  is  increased,  if  one  makes  a  journey 
over  a  rough  road,  would  lead  one  to  think  of  a  kidney  stone, 
further  signs  of  which  are  disclosed  upon  examination. 

Pancreas,  Spleen,  etc.  — Of  the  pains  of  many  pancreatic  af- 
fections, it  is  likewise  known  that  they  radiate  in  the  back,  or  (in 
girdle  form)  towards  the  front.  Frequently  diseases  of  the 
female  geniialia  lead  to  severe  pelvic  pain,  and  finally  the  spleen, 
also,  under  some  conditions,  produces  pain  which  radiates  into 
the  pelvis,  the  left  shoulder,  the  left  shoulder  blade,  and  the  inter- 
scapular region.  Spleen  tumors,  especially,  produce  pain,  and 
their  presence  will  be  thought  of  as  an  associated  condition  by 
the  presence  of  the  above  described  pain. 

The  pelvic  organs  (uterus  and  ovary)  are  probably  the  most 
frequent  causes  of  backache  in  women.  The  principal  lesions  are 
a  malsituated  uterus  (retroversion,  retroflexion,  or  the  binding  of 
it  down  to  the  pelvic  floor  by  adhesions,  in  which  the  pain  is 
worse  just  before  the  menstrual  period)  ;  and  inflammation  of  the 
uterosacral  ligaments  (Garrigues,  803).  Tender  spots  on  either 
•  side  of  the  second  sacral  vertebra  are  due  (Garrigues)  to  cellulitis 
of  the  uterosacral  ligaments.  Pressure  over  the  inflamed  utero- 
sacral ligaments  produces  pain  at  these  places.  The  pain  is  worse 
on  exertion,  especially  in  sweeping.  Sexual  intercourse  is  pain- 
ful, as  a  rule.  Examination  will  disclose  the  abnormal  and  pain- 
ful ligaments.  Pregnancy  and  menstruation  are  also  potent  causes 
for  backache;  but  in  these  conditions  there  is  generally  present 
some  previous  disturbance  of  the  lumbar  structures  which  pre- 
dispose them  so  that  the  addition  of  congestion  or  traction,  result- 
ing from  pregnancy  or  menstruation,  produces  pain.  In  some 
cases,  during  pregnancy,  an  actual  relaxation  of  the  sacroiliac 
ligament  is  present  (Andrews  and  Hoke,  806). 


304  REGIONAL   PAINS 

Inflammations  of  the  uterus  may  also  cause  backache.  (For 
a  fuller  consideration,  see  "Pain  in  the  Female  Genitalia,"  Chap- 
ter XXXIL) 

The  genitouriimry  organs  in  the  male  (prostate,  seminal 
vesicles)  cause  lumbar  pain.  The  urinary  bladder,  also,  when 
diseased,  frequently  gives  rise  to  pain  in  this  region. 

Back  pain  may  also  be  caused  by  static  foot  errors,  hysteria, 
anemia  and  chlorosis. 

In  static  foot  errors  the  pain  is  relieved  on  the  patient  lying 
down,  or  on  the  correction  of  the  errors  of  position. 

"In  hysteria  the  backache  is  usually  referred  to  the  lumbar  and 
sacral  regions.  It  often  extends  upward  over  the  dorsal  area  and 
downward  over  the  gluteal  muscles"  (Clara  F.  Dercum,  150). 

Anemia  and  Chlorosis.  - — The  anemic  and  chlorotic  individual 
very  frequently  complains  of  back  pain.  It  occurs  as  rheumatic 
pain,  which  is  most  severe  in  the  morning,  after  arising,  and  im- 
proves during  the  forenoon,  if  the  patient  moves  about. 

The  lesions  of  the  spinal  cord  causing  back  pain  have  been 
previously  considered,  and  will  not  be  dwelt  upon  here. 

PAIN    IN    THE    LIMBS 

After  the  consideration  of  back  pains,  it  is  next  in  order  to 
discuss  the  pains  which  usually  are  present  in  the  limbs.  The 
upper  limbs  are  probably  not  so  frequently  subjected  to  pain  sen- 
sation as  are  the  lower  limbs;  and  when  they  are,  the  causative 
factor  is  more  likely  to  be  of  a  circulatory  nature.  The  principal 
pain  areas  are  in  the  joints,  which  are  frequently  affected  by 
rheumatism.  The  shoulder  joint,  in  particular,  is  subject  to 
gonococcus  infection.  Over  the  shoulder  are  also  found  the  re- 
flected pains  from  the  liver  on  the  right  side,  and  from  the  spleen, 
pancreas  and  stomach  on  the  left  side.  On  both  sides  pains  re- 
flected from  the  diaphragm,  extrauterine  pregnancy  and  pleura 
are  found.  In  the  shoulder  also  is  present  the  pain  resulting 
from  inflammation  of  the  deltoid  bursa,  which  lies  between  the 
humerus  and  the  acromion  process  of  the  scapula.     A  characteri§- 


PAIN   IN    THE    LIMBS  305 

tic  of  this  pain  is,  that  it  is  caused  by  elevating  the  shoulder,  and 
is  very  severe  until  the  arm  becomes  horizontal,  when  the  pain  dis- 
appears. The  pain  is  localized  immediately  below  the  acromion 
process,  between  this  process  and  the  head  of  the  humerus.  Ten- 
derness is  also  most  marked  at  this  point. 

Generalized  pains  are  usually  neuralgic  in  origin  (for  which 
the  reader  is  referred  to  the  section  under  Brachial  Neuralgia). 

The  LowEK  EXTREMITIES  are  greatly  affected  by  circulatory 
changes.  A  slight  indication  of  the  type  the  symptoms  may  as- 
sume is  given  by  the  so-called  sleeping  pains  which  follow  upon 
the  partial  stopping  of  the  circulation  in  a  limb.  Generalized 
pain  of  a  paroxysmal  character,  more  pronounced  On  the  external 
and  posterior  surfaces  than  on  the  internal  surface  of  the  limb, 
is  likely  to  be  due  to  a  sciatica  (a  complete  description  of  which 
is  given  in  a  separate  section).  When  the  pain  is  on  the  anterior 
surface  of  the  thigh,  and  runs  down  and  to  the  inner  side,  it  is 
probably  due  to  involvement  of  the  anterior  crural  nerve.  Should 
neuralgia  be  present  the  pain  is  paroxysmal  and  is  of  great  in- 
tensity. If  it  is  a  referred  pain  from  pressure  on  the  nerve  from 
tumors  or  bowel  accumulations  (William  Bruce,  .502),  it  is  more 
of  a  steady,  constant,  dull  ache. 

In  the  lower  limbs,  the  joints,  especially  the  hip  joints,  are 
very  prone  to  tuberculous  infection.  The  hip,  when  so  affected, 
at  first  causes  a  pain  on  the  inner  side  of  and  somewhat  posterior 
to  the  knee;  so  that,  in  many  cases,  disease  of  the  knee  joint  is 
falsely  diagnosed.  Rheumatism  is  also  common  in  these  joints, 
and  frequently  pain  and  swelling  in  the  knee  follow  upon  the 
locking  of  the  joint  by  a  so-called  rice  body.  The  pain  is  due  to 
a  stretching  of  the  ligaments.  It  may  be  only  a  pinching  pain,  or 
it  may  be  excruciating,  if  the  cartilages  are  caught  (Barker) . 

Flat-foot,  also,  is  a  potent  cause  of  pain  in  the  region  of  the 
knee.  The  pain  is  on  the  inner  side  of  the  patella  and  may  radi- 
ate up  and  down  the  front  of  the  leg.  The  pain  is  much  in- 
creased on  active  exercise  of  the  foot,  especially  by  running  or 
walking.  Pain  in  the  legs  which  is  not  influenced  by  position, 
pressure,  heat  or  cold    is  often  the  forerunner  of  brain  hemor- 


306  REGIONAL   PAINS 

phage.  When  it  occurs  in  persons  of  advanced  years,  with  hard 
arteries,  it  should  be  looked  upon  with  suspicion  (Musser). 

At  times  the  heel  is  very  painful  (pododynia) — so  much  so 
that  the  patient  is  unable  to  walk.  This  pain  may  be  due  to  local 
conditions  (exostoses  on  the  surface  of  the  os  calcis).  Those  on. the 
posterior  and  inferior  surfaces  are  the  most  frequent  (Thorndike, 
"Orthopedic  Surgery,"  p.  164)  ;  there  may  also  exist  spurs  run- 
ning out  from  the  under  side  of  the  os  calcis ;  bursitis  of  the  bursa 
under  the  os  calcis;  or  an  associated  flat-floot  may  be  present 
(Keen's  "System  of  Surgery,"  Vol.  II,  p.  56).  Painful  swelling 
may  also  be  present  on  the  posterior  surface  of  the  heel  at  the 
insertion  of  the  tendon-achilles  into  the  os  calcis.  The  patient 
walks  with  the  feet  everted,  while  the  use  of  the  calf-muscles  is 
painful.  Pain  in  the  heel  may  also  be  caused  by  lesions  which 
are  at  a  distance,  as  from  uretliral  stricture  (Luxmoor,  Brodie, 
Thompson,  Van  Buren,  Keyes,  and  Gouley),  vesicle  calculus,  cys- 
ticoprostatitis,  inflammation  of  the  neck  of  the  bladder,  cystalgia, 
or  neuralgia  of  the  neck  of  the  bladder,  which,  in  some  cases,  may 
be  mistaken  for  bladder  stone  (Von  Pitha,  272),  renal  calculus, 
gonorrhea  (Fournier,  274),  and  locomotor  ataxia  (Begun  and  Buz- 
zard). It  is  also  jDresent  in  pregnancy.  Pain  on  the  sole  of  the 
foot  may  be  caused  by  exostoses  on  the  internal  cuneiform  or  the 
base  of  the  first  metatarsal,  or  at  the  junction  of  the  scaphoid  and 
cuneiform  (Thorndike). 

A  peculiar  and  painful  affection  of  the  foot,  occurring  only 
in  adults,  and  most  frequently  in  women,  is  termed  metatarsalgia 
(Morton's  disease). 

"Typical  cases  of  this  affection  have  sudden  cramp-like  pains 
starting  in  the  third  or  fourth  metatarsophalangeal  articulation 
and  radiating  to  the  tips  of  the  toes  and  up  the  leg.  The  sudden 
onset  may  be  brought  on  by  a  misstep,  or  by  the  fatigue  of  stand- 
ing a  long  time,  and  occurs  almost  invariably  when  the  shoes  are 
worn.  In  some  attacks  are  infrequent ;  in  others  they  practically 
disable  the  jDatient  and  are  provoked  by  inappreciable  causes.  The 
pain  is  so  great  that  the  patient  removes  the  shoe,  rubs  and  com- 
presses the  front  of  the  foot,  flexes  and  extends  the  toes,  and,  after 


PAINS    IN    THE   ABDOMEN  307 

a  time,  the  pain  ceases,  leaving  no  sign,  or  only  a  very  slight  sore- 
ness over  the  articulation  on  deep  pressure.  The  cramp-like  pain 
may  be  referred  to  a  single  or  to  several  adjoining  joints  or  to  all 
the  bones  of  the  metatarsal  articulation.  It  is  due  to  a  pinching 
of  the  j)lantar  nerve  between  the  bones,  or  to  an  abnormal  strain 
on  the  ligaments  connecting  the  heads  of  the  metatarsal  bones" 
(Thorudike). 

Tenderness  is  found  on  pressure  over  the  heads  of  one  or  more 
metatarsal  bones,  or  on  lateral  pressure  in  the  region  of  the  meta- 
tarsophalangeal joint  (Forbes,  Montreal  Med.  Journ.,  April, 
1909). 

PAINS   m   THE  ABDOMEN 

If  a  pain  is  of  a  i^eculiar,  dragging  nature,  increased  on  breath- 
ing, and  esj)ecially  when  deep  inspiration  or  complete  expiration 
is  performed,  and  if  it  runs  round  the  chest  from  the  ensiform 
cartilage  in  a  slightly  do\\aiward  direction  to  the  tenth  rib  pos- 
terior, it  is  generally  the  result  of  diaphragmatic  traction.  It  oc- 
curs in  great  cardiac  and  respiratory  activity,  dilatation  of  the 
stomach,  severe  tympany,  coughing,  sneezing,  or  hiccoughing.  A 
pain  slightly  lower,  and  restricted  to  the  area  of  the  liver,  may  be 
caused  by  hepatitis  (see  Liver).  On  the  left  side,  over  the 
area  of  the-  spleen,  a  perisplenitis  similarly  will  cause  a  pain. 

Pain  localized  immediately  in  the  middle  of  the  abdomen,  be- 
tween the  ensiform  and  the  umbilicus,  may  be  due  to  pancreatitis, 
ulcer  of  the  stomach,  gall-stones,  cardiac  lesions  (tricuspid  regur- 
gitation), liver  and  adnexal  diseases,  epigastric  hernia,  and  duo- 
denal ulcer.  If  the  pain  is  located  around  the  umbilicus,  the 
causative  lesion  may  be  a  hernia  of  the  linea  alba,  volvulus,  em- 
bolus of  the  superior  mesenteric  artery,  meteorism,  tympany,  in- 
testinal obstruction,  swollen  mesenteric  glands,  early  stage  of 
appendicitis,  ileocolitis  and  intestinal  strangulation. 

Pain  downward  and  slightly  to  the  right  is  very  severe  in 
appendicitis,  oophoritis  and  salpingitis.  Pain  on  the  left  side  is 
severe  in  salpingitis  and  oophoritis.  On  either  side  pain  running 
from  the  back  around  to  the  anterior  surface  of  the  abdomen  and 


1 

Diaphragmatic  trac- 
tion, as  in  great 
cardiac  and  respir- 
atory activity 

Dilatation  of  stom- 
ach 

Coughing,  sneezing, 
hiccoughing 


Perihepatitis 


Ovaries  and  tubes 


Appendix  and  Fal- 
lopian tubes 


Broad  ligament 

6 
Femoral  hernia 
Inguinal  and  femor- 
al adenitis 


Pain  radiating  down 

to  foot 
Phlebitis 
Crural  neuralgia 
Disease  of  femur 
Femoral  hernia 
Abdominal    tumors 
pressing  on  crural 
nerve: 
Aneurysm 
Uterine  or  ova- 
rian tumors 
Tuberculous 
abscess  (psoas) 

8 
Joint 

Rheumatism 
Tuberculosis 
Inflammation 
Stretching  of  liga- 
ments 


Erythromelalgia 
Neuritis 

Premonitory  of  apo- 
plexy 
Disarticulation 
Artie,  cartilages 

10 
Lithemia 

Spurs  on  os  calcis 
Bursitis  under  os 

calcis 
Associated  flat-foot 


Gout 
Bunion 


11 


Fig.  74. — Pain  Areas  in  Trunk  and  Lower 
Extremities. 


12 
Cancer  of  breast 
Mastitis 
Uterine  disease 

13 
Splenic  disease 
Perisplenitis 

14 

Pancreatitis 

Ulcer  of  stomach  or 
duodenum 

Gall-stones 

Cardiac  lesions  (tri- 
cuspid regurg.) 

Liver  involvement 

15 

Hernia  of  linea  alba 

Volvulus 

Embolus,  sup.  mes. 
artery 

Meteorism 

Tympany 

Intestinal  colic 

Intestinal  obstruc- 
tion 

Intestinal  strangula- 
tion (hernia) 

Swollen  mesenteric 
glands 

Peritonitis  (general- 
ized) 

16 

Bladder  lesions  (cys- 
titis, etc.) 

Uterine  lesions 

Renal  and  ureteral 
colic 

Lesions  of  large 
intestines,  colic, 
etc. 

Embolus  of  inf. 
mes.  artery 

Tubo-ovarian  dis- 
ease 

Pelvic  peritonitis 

Rupture  of  abdom- 
inal hollow  viscus 

Extra-uterine  preg- 
nancy 

Pelvic  cellulitis 
(broad  ligaments) 

17 
Referred  pain  in  hip 

joint  disease 
Obturator  hernia 

18 
Tender      point     in 
flat-foot 
19 
Pain  in  flat-foot 

20 
Postcalcaneal    bur- 
sitis 

21 
Disease  of  ovary 
Neurasthenia 

22 

Morton's    disease 

(metatarsalgia) 


Pain  above  the  um- 
bilicus 
Lesions    of   small 
intestine 
Strangulation 
Volvulus 
Intussusception 
Embolus  sup.  mes. 

artery 
ArterioscI  e  r  o  s  i  s 

sup.  ma. 
Pancreas  disease 
Inflammation 
Cancer 
Liver,  gall-bladder 
or  duct  disease 
Stomach  disease 


Pain  below  umbili- 
cus 
Colonic  disease 
Cancer 

Intussusception 
Colonic    impac- 
tion 
Rectal  disease 

Cancer 
Embolus  inf.  mes. 
artery 


Fig.  75 — Pain  Areas  in  Breast  and 
Abdomen. 


Breast  diseases 
Uterine  disease 
Pregnancy 
Menstruation 


Circum  umbilical 

pain 
■    Appendicitis 

Typhlitis 

Perityphlitis 

Ileum  disease 
Pain  over  entire  ab- 
domen 

Peritonitis 

Rhe-'matism  or 
neuralgia  of  the 
abdominal   wall 

Intestinal  perfor- 
ation 

Tympanites 

Pneumonia  (chil- 
dren) 

Aneurysm  (abd. 
aorta) 


309 


310  REGIONAL   PAINS 

then  down  to  the  testicle  or  labia  generally  indicates  a  renal  or 
ureteral  disorder. 

Pain  below  the  umbilicus  in  the  mid-line  is  found  in  colonic 
disease,  rectal  disease,  embolus  of  the  inferior  mesenteric  artery, 
uterine  disease,  or  disease  of  the  urinary  bladder. 

Pain  over  the  entire  abdomen  results  from  disease  of  the 
abdominal  wall  (myalgia,  neuralgia,  rheumatism,  peritonitis),  in- 
testinal perforation,  tympanites,  enteroptosis,  referred  pain  in 
pneumonia  (in  children),  and  aneurysm.  For  a  more  complete 
discussion  of  abdominal  pain,  see  Chapter  XIX. 
.    Pains  due  to  tabes  are  very  frequent  in  the  abdomen. 

CHEST   PAIN 

Pain  over  the  chest  in  the  sternal  region  may  be  caused  by 
diseased  bone,  mediastinal  inflammation,  changes  in  the  medias- 
tinal glands,  aortic  aneurysm,  bronchitis  and  stomach  disorders. 
Over  various  areas  in  the  chest  are  the  pains  from  pneumonia 
and  pleurisy.  Radiating  around  the  chest  wall  and  paroxysmal 
in  type  are  the  pains  of  intercostal  neuralgia  and  vertebral  and 
cord  diseases.  Pain  localized  to  the  pectorals  and  made  worse  on 
raising  and  lowering  the  arm  results  from  rheumatism  of  the 
pectoral  muscle.  It  can  also  be  the  result  of  invasion  of  the 
pectorals  in  cancer  of  the  breast. 

Pain  on  the  left  side,  over  the  cardiac  region,  indicates  a 
possible  lesion  of  the  heart,  and  this  is  confirmed,  if  it  is  found  that 
the  pain  runs  down  the  ulnar  side  of  the  arm;  even  as  far  as  the 
little  finger.  Pain  in  the  breast  is  frequently  present  during 
menstruation,  in  pregnancy,  and  in  uterine  and  ovarian  diseases. 
It  may,  also,  be.  the  result  of  a  local  inflammation,  in  which  case 
the  entire  breast  is  markedly  tender  and  signs  of  inflammation  are 
present. 

CLAVICULAR   PAINS 

Pain  in  the  clavicular  region  is  frequently  associated  with 
new  growths  (pleura,  clavicle),  aneurysm  of  the  subclavian,  and 
pulmonary  tuberculosis.     In  the  supraclavicular  region  it  may  be 


3 

Sternomaatoid 
disease       (wry- 
neck) 

4 

Liver  disease 

Extrauterine    preg- 
nancy    (in     fe- 
male) 

Suprarenals 

Diaphragmatic 
pleurisy 

Colon 

5 

Disease     of      bone 
(sternum) 
Necrosis 
Tuberculosis 
Periostitis 

Mediastinal  inflam- 
mation 

Mediastinal  glands 
Inflammation 
Enlargement 

Aneurysm  of  aorta 

Bronchitis 

Stomach 
Hyperchlorhydria 

I 
2 
3 
4 
5 
6 
7 

8 

9 
10 
11 

6 

12 

Circumflex    neural- 

gia 

7 
Pectoral  neuralgia 

13 

8 

Axillary   gland    in- 
volvement 

9 
Intercostal    neural- 

gia 
Necrosis  rib 

10 

Girdle  pain-tabes 
Diap hragmat  ic 
traction     in 
coughing, sneez- 
ing    and     hic- 
coughing 

11 

Hepatic  congestion 
Hepatitis 
Referred  pain 

Pneumonia 

Pleurisy 

Vertebral  diseases 
Tabes 

Subphrenic  abscess 
Nephroptosis 

12 

Gall  bladder  disease 
Pancreatic  disease 
Gall  duct  disease 

13 

Renal  colic 
Ureteral  colic 

Mental  neuralgia 
Toothache 
Disease  of  inf.  max. 


Laryngeal  disease 
Thyroid  disease 
Tracheitis 


Fig.  76. — Pain  Areas  in  Neck,  Chest, 
Clavicular  Region  and  Abdomen. 


14 

Parotiditis 
Ear  disease 
Toothache 

15 

Tonsillitis 
Pharyngitis 
Ludwig's  angina 
Inflammation       o  f 
base  of   tongue 
or  submaxillary 
gland 

14 

16 

15 
16 
17 

Spleen 

Stomach 

Colon 

18 
19 

17 

20 
21 

22 
23 

New  growths,  glan- 
dular, etc. 

Aneurysm,  subclav- 
ian 

Pulmonary  tuber- 
culosis 

24 

18 

25 

Deltoid  bursitis 

19 

Lung  disease 
Pectoral  neuralgia 

27 

20 

Cardiac  disease  (an- 
gina pectoris) 

21 

Pancreatic  disease 
Cholelithiasis 

22 

Mastitis 
Pericarditis 
Stomach  disease 
Uterine    and    ovar- 

ian pregnancy  (in 
female) 

23 

Stomach  lesions 
Pneumonia 

24 

Spleen 

Perisplenitis 
Displacement 

25 

Gastric  disease 
Pancreatic  disease 

26  and  27 

Epididymis 

Swollen  and  in- 
flamed inguinal 
glands 

Inguinal  hernia 

311 


312  REGIONAL   PAINS 

due  (on  the  right  side)  to  liver  disease,  or  (on  the  left  side) 
to  disease  of  the  colon  or  stomach  (in  new  growth  of  which  also 
search  for  metastatic  glands  in  this  region).  In  extrauterine  preg- 
nancy with  rupture,  pain,  when  present,  is  on  the  same  side  as 
the  rupture;  in  colonic  disease  and  diaphragmatic  pleurisy,  pain, 
as  a  rule,  is  on  the  diseiased  side.  Pain  over  the  shoulder  is  present 
i:i  deltoid  bursitis  and  also,  in  a  wider  area,  in  neuralgia  of  the 
circumflex. 

NECK   PAINS 

When  a  patient  complains  of  pain  in  the  neck,  the  first  idea 
suggested  to  the  physician  is  that  he  is  sufi"ering  from  some  in- 
flammatory disease  of  the  upper  respiratory  passages.  This  idea 
is  increased  almost  to  a  certainty  if,  with  the  pain,  there  is  also 
present  an  inspiratory  stridor.  It  may  be  a  sign  of  laryngitis, 
thyroiditis,  or  tracheitis.  Should  pain  be  felt  only  on  turning 
the  neck  to  one  side  or  the  other,  and  should  one  of  the  sterno- 
mastoids  be  in  a  state  of  tonic  contraction,  sternocleidoid  disease 
or  wry-neck  is  indicated  (see  Fig.  G9).  This  tendency  to  lateral 
flexion  and  rotation  is  also  seen  at  times  in  brachial  neuralgia. 
Pain  above  the  sternomastoid  and  below  the  inferior  maxillary  is 
found  in  tonsillitis,  inflammation  of  the  inferior  maxillary  gland, 
or  in  inflammation  of  the  floor  of  the  mouth,  the  so-called  Ludwig's 
angina.  Pain  over  the  os  hyoides  or  larynx  is  a  sign  of  inflamma- 
tion of  the  bone.  In  some  cases  an  inferior  maxillary  neuralgia 
may  be  present.  Pain  just  anterior  to  the  ear,  on  the  side  of  the 
face,  indicates  ear  disease,  jiarotitis,  or  diseased  teeth  (inferior 
maxillary). 

SUMMARY 

Pain  in  the  back,  over  the  entire  vertebral  column,  indicates 
neurasthenia,  traumatic  spine  or  mediastinal  disease;  in  the  area 
between  the  scapula  it  indicates  pericarditis,  lung  disease,   dia- 


SUMMARY 


313 


phragmatic  i^leurisy  and  aortic  lesions ;  over  the  scapula,  lung  in- 
volvement or  pleurisy  is  indicated. 

On  the  left  side,  between  the  vertebrae  and  the  scapula,  pain 


Spleen 
Pericarditis 
Diaphragmat  ic 
pleurisy 


Lung  disease 
Pleurisy 


Splenic  involve- 
ment 


Aortic  aneur- 
ysm (gnawing 
pain) 

Stomach 

Overdisten- 

tion 
Inflammation 
Ulceration 

Liver 


Vertebral      dis- 
ease 

T.  b.  c.  tu- 
mors, frac- 
tures 
Cord  (crush, 
fractures, 
etc.) 
Liver 


6 

Kidneys 


Sacroiliac      dis- 
ease 


Pain  Areas  in  the  Back. 


8 

Liver,  gall  blad- 

der 

9 

Headache,  back 

of        head, 

pain     radi- 

ating down 

the       back 

from   brain 

pressure 

10 

Pericarditis, 

lung  disease 

Diaphragmatic 

pleurisy 

8 

Aortic  lesions 

9 

11 

Vertebral      and 

10 

rnediastinal 

disease 

12 

11 

Liver  disease 
13 

12 

Lungs:  pneu- 

13 

monia,  pleu- 

ral disease 

Rib  disease 

14 

Intercostal  neu- 

ralgia 

15 

Pleurodynia 

14 

Tabes,        local- 

ized menin- 

16 

gitis 

15 

Liver    (perihep- 

atitis) 

17 

E  iaphragmatic 

disease 

IG 

Lidneys     (peri- 

nephritic 

abscess) 

C'dlon  impacted 

Retroperitoneal 

glandular 

enlargement 

17 

Disease  of  coc- 

cyx 

Cervicitis 

Anal  fissure 

Hemorrhoids 

is  present  in  aortic  lesions  and  stomach  disorders ;  at  the  apex  of 
the  scapula,  on  the  left  side,  splenic  disease  is  indicated ;  and,  at 
about  the  same  level  on  *the  right  side  (in  many  cases  a  little 
lower),  liver  disease  is  indicated.  Pain  generalized  over  the  back 
of  the  chest  may  be  due  to  myalgia,  lung  or  pleural  disease.  Pain 
radiating  around  the  side  of  the  chest  is  due  to  intercostal  neu- 
ralgia. By  reference  to  Fig.  78,  the  local  points  of  tenderness  in 
brachial  neuralgia  and  in  the  so-called  diaphragmatic  neuralgia 


314 


REGIONAL   PAINS 


are  shown,  as  well  as  the  points  of  tenderness  in  intercostal  neu- 
ralgia and  in  angina  pectoris. 


Pain  in  pulmonary  \ 
tuberculosis 

Dots  indicate  points 
of  tenderness  in 
intercostal  neu- 
ralgia 


General  tenderness 
over  all  the  verte- 
brse  in  neuras- 
thenia 

Subacromial  bursi- 
tis 

Trousseau's  points 
of  tenderness  in 
diaphragmatic 
neuralgia 


Plane  of  emergenf 
of       the       dors; 


Uterus 
Ovaries 
Colon 
Rectum 


Subjective  pain 
Hypertension  head- 
ache 


Spine    of    the    7th 
cervical  vertebra 
1  Painful     points     in 
angina  pectoris 

Trousseau's     point 
of    local    tender- 
ness for  brachial 
,       neuralgia 

Tender  points  over 
the  2nd  and  3rd 
dorsal  spine  in 
brachial  neuralgia 

Spinous  processes 
all  tender  in  neu- 
rasthenic spine 

r  Pressure  causes  pain 
in 

1.  Spinal  caries 

2.  Aneurysm 

3.  Spinal  menin- 
gitis 

4.  Tuberculosis 


Uterine  disease 
Kidney  disease 
Lumbago 

Acute  infectious  dis- 
eases 


Fig.  78. — Pain  Areas  in  Spinal  Column. 


Lower  down  in  the  back,  in  the  neighborhood  of  the  lower  ribs, 
are  fonnd  the  areas  which  are  painful  in  perihepatitis  and  dia- 
phragmatic disease,  while  a  little  lower  is  found  the  area  in  which 
pain  is  located  in  kidney  disease.  Lower  still,  and  in  the  neigh- 
borhood of  the  sacrum,  are  the  areas  where  pain  is  present  in  colon 
involvement,  retroperitoneal  gland,  and  uterine  disease.  In  the 
entire  small  of  the  back  are  found  the  occupation-pain,  uterine- 


SUMMARY 


315 


disease  pain,  perinephritic-abscess  pain,  lumbago,  and  lumbar- 
abscess  (tubercular)  pain.  In  the  same  area,  but  extending  over 
tbe  sacroiliac  articulation,  is  the  pain  of  sacroiliac  disease.  Over 
the  coccyx  and  adjacent  regions  is  located  the  pain  due  to  disease 


Area  of  re- 
ferred pain  in 
liver  disease 


Aortic      aneur- 
ysm 

3  and  4 
Tender     points 
often  present 
in  gastric  ad- 
hesions 


Renal  disease 
Perirenal       ab- 
scess 
Lumbar  abscess 
Lumbago 


Neurasthenia, 
pain  running 
along  verte- 
bral column 


Tuberculous  ca- 
ries 


Intercostal 

neuralgia 
Herpes 


Fig.  79. — Pain  Areas  in  Back. 


Spleen 

10 
Area  of  tender- 
ness in  gastric 
ulcer 


11 
Uterine  disease 
Postoperative 
Occupation  tire 
Surgeons 
Dentists 
Clerks,  etc. 
Appendicitis 

12 

Uterus 

Sacroiliac      dis- 
ease 

13 

Sacroiliac      dis- 
ease 

14 
Coccyx  injuries 

and  disease 
Rectal  disease 
Cervical  disease 

15 
Broad  ligaments 
Ovaries  (Butler) 


of  the  coccyx,  rectal  disease,  and  cervix  disease.  Pain  over  the 
buttocks,  and  running  down  the  outer  surface  of  the  limb,  is 
especially  frequent  in  ovarian  and  broad  ligament  disorders. 

Pain  in  the  inguinal  region  may  be  due  to  inguinal  or  femoral 
adenitis,  and  if  it  radiates  down  toward  the  foot  it  may  be  due  to 
phlebitis,  crural  neuralgia,  disease  of  the  femur,  femoral  hernia, 
abdominal  tumors  pressing  on  the  crural  nerve  (aneurysm,  uterine 
or  ovarian  tumors,  tuberculous  abscess  of  the  psoas). 

Pain  in  a  joint  may  result  from  rheumatism,  tuberculosis, 
acute  synovitis,  stretching  of  ligaments,  or  floating  bodies. 


CHAPTEK  XV 

THE  SIGNIFICANCE  OF  PAIN  IN  DISEASE  OF  THE  EYE  ^ 

When  sensitive  and  sensory  impressions  falling  upon  the 
retina  exceed  a  certain  maximum  in  intensity  they  become  dis- 
agTeeable.  If  their  intensity  reaches  a  still  higher  degree  the 
sensation  provoked  is  painful.  Just  what  are  the  threshold  values 
for  various  forms  of  stimuli  of  the  retina  are  not  all  determined. 
Thus,  the  action  of  very  strong  light  on  the  eye  causes  a  painful 
sensation,  with  blinding.  Such  sensations  scarcely  ever  arise 
spontaneously.  They  are  nearly  always  the  result  of  the  action 
of  adequate  stimuli  which  have  been  increased  above  the  normal 
limits.  These  disagreeable  sensations  are  to  be  distinguished  from 
others  due  to  irritation  of  the  nerves  of  common  sensation.  In 
the  descriptions  to  follow  the  latter  will  be  simply  called  pain. 

Under  normal  conditions  an  individual  is  not  ordinarily  con- 
scious of  the  normal  retinal  stimuli,  and  if  the  existence  of  this 
organ  intrudes  itself  upon  consciousness  this  is  usually  a  sign  of 
a  pathological  condition.  Xhis  consciousness  is  usually  brought 
about  through  the  medium  of  pain.  As  we  do  not  possess  any 
objective  method  for  measuring  pain,  we  must  rely  upon  the 
information  given  by  the  suffering  individual,  which  must  be 
checked  up  by  our  own  experience.  Self-training,  self-control, 
physical  and  psychical  distraction  are  circumstances  which  con- 
siderably influence  the  intensity  of  this  pain  perception,  increas- 
ing, diminishing,  or  even  abolishing  it  completely. 

The  same  uncertainty  which  exists  in  the  estimation  of  the 
intensity  of  the  pain  dominates  the  characterization  of  the  quali- 

1  By  Decent  Hans  Lauber,  M,  D.,  and  Olaf  Kuttin,  M.  D.,  assistants  of 
the  Eye  Clinic,  Vienna. 

316 


ETIOLOGY  317 

ties  of  pains.  In  the  same  disease  the  same  pain  will  not  be 
described  in  the  same  way  by  several  patients,  and  will  be  differ- 
ently described  by  the  same  patient  at  different  times.  The  pain 
may  be  described  as  blunt,  dull,  boring,  burning,  pulling,  throb- 
bing or  tearing,  but,  unfortunately,  there  is  no  possibility  of  ascer- 
taining whether  the  similar  terms  used  by  different  patients 
describe  similar  sensations. 

As  far  as  the  duration  of  pain  is  concerned,  we  are  in  a  far 
better  situation.     We  can  more  easily  believe  the  correctness  of 
statements  which  describe  pain  as  continuous,   periodical,  inter- 
mittent,  or  periodically    exacerbating.     Under    certain    circum-. 
stances  these  characterizations  can  be  of  great  diagnostic  value. 

ETIOLOGY 

In  examining  the  different  factors  that  can  cause  or  increase 
pain  in  the  eye,  or  its  surroundings,  we  find  that  they  may  be 
touch,  pressure,  atmospherical  influences,  temperature,  light,  and 
tiring  of  the  eyes  by  work. 

The  topography  of  the  eye  and  its  adnexa  points  to  the  rami- 
fication of  the  first  and  second  branches  of  the  fifth  nerve  as  the 
source  of  the  tactile  and  consequently  also  of  painful  sensations. 
The  third  branch  is  of  but  secondary  importance.  All  the  other 
nerves  can  be  excluded  from  further  consideration.  As  a  conse- 
quence of  the  very  extensive  ramification  of  the  fifth  nerve,  it  is 
found  that  irritation  of  different  branches  of  the  nerve  may  pro- 
duce a  sensation  of  pain,  or  even  other  symptoms,  in  the  ocular 
region.  It  is  important  to  emphasize,  at  the  very  beginning,  that 
irritation  of  any  branch  of  the  trigeminus  may  provoke  a  sensa- 
tion of  pain  in  its  whole  distribution,  and,  further  still,  reflex  pain 
can  be  elicited  in  all  those  nerves  that  are  in  close  anatomical  or 
physiological  relation  to  the  irritated  nerve — for  instance,  the  in- 
timate association  of  lachrymation  to  irritation  of  the  trigeminus. 
Mechanical  influences,  acting  upon  the  cornea,  elicit  lachrymation, 
iust  as  easily  as  can  the  irritation  of  a  tiny  nerve  stem  in  the  pulp 
cavity  of  a  tooth,  or  the  irritation  of  the  nasal  mucous  membrane, 


318        SIGNIFICANCE    OF    PAIN   IN   DISEASE    OF    EYE 

which  are  likewise  innervated  by  the  fifth  nerve.  Irritation  of 
the  bulbar  terminal  branches  of  the  fifth  nerve  is  generally  accom- 
panied by  hyperemia,  which  extends  from  tlie  immediate  sur- 
roundings of  the  irritated  place  to  the  neighboring  parts,  and  can 
lead  to  visible  hyperemia  of  the  conjunctiva.  The  numerous  anas- 
tomoses of  the  fifth  nerve  with  the  seventh  and  the  sympathetic 
explain  the  frequent  reflex  phenomena,  such  as  sneezing,  swallow- 
ing, pupillary  dilatation,  vasomotor  and  secretory  disturbances. 
All  these  reflexes  can  occur  in  association  with  pain  in  the  realm 
of  the  fifth  nerve. 

From  a  practical  standpoint,  pain  is  very  important  in  a 
double  sense,  first,  as  a  symptom  of  partial  disturbance,  which  is 
often  vague  and  allows  many  different  explanations ;  second,  as 
the  patient's  prominent  subjective  complaint,  by  the  removal  of 
which  the  physician  can  gain  much  credit. 

LOCALIZATION   OF   PAINS 

The  exact  localization  of  pains  in  the  eye  region  may  be  of 
symptomatic  significance,  yet  here  we  encounter  many  uncertain- 
ties. In  a  case  of  iritis,  for  instance,  we  firmly  believe  that  the 
pain  originates  in  the  ramification  of  the  fifth  nerve  in  the  iris 
itself,  and  yet  many  patients  do  not  complain  of  pain  in  the  eye, 
but  in  the  bone  surrounding  the  orbit.  The  pain  in  glaucoma 
has  its  source  in  the  globe ;  nevertheless,  many  patients  complain 
only  of  headache  or  hemicrania  until  the  tenderness  of  the  globe  on 
pressure  convinces  them  that  the  eyeball  is  the  aifected  organ. 
^Notwithstanding  the  fact  that  the  localization  of  the  pain  may 
lead  to  false  judgments,  the  following  pages  will  attempt  a  diag- 
nostic analysis  of  pain,  based  upon  its  localization. 

The  Eyelids.  — The  skin  of  the  eyelids  and  their  surroundings 
may  be  a  source  of  intense  pain  in  cases  of  inflammation.  This 
pain  may  be  spontaneous,  and  is  generally  very  intense  when  the 
inflamed  skin  is  touched.  This  kind  of  pain  which  is  localized  in 
the  skin  occurs  in  eczema,  febrile  herpes,  herpes  zoster,  cases  of 
phlegmon  and  abscesses  of  this  region.     In  many  cases  the  pain  is 


LOCALIZATION    OF    PAINS  319 

associated  with  swelling  of  the  tissues,  so  that  the  real  focus  of 
the  disease  can  be  found  on  palpation.  In  marked  inflammatory 
edema  of  the  lids  one  finds  on  touch  an  increased  resistance  of 
the  tissue,  which  is  considerably  increased  in  some  places.  If  the 
region  of  the  internal  can  thus  ligaments  be  the  seat  of  tenderness 
to  palpation  the  possibility  of  a  beginning  dacryocystitis  or  peri- 
ostitis should  be  thought  of.  Pain  and  resistance  at  the  margin 
of  an  eyelid  suggest  a  hordeolum ;  superficial  pain  of  the  skin, 
accompanying  movable  resistance,  points  to  the  diagnosis  of  a 
furuncle  or  an  abscess,  whereas  an  immobile  resistance  is  an  argu- 
ment in  favor  of  periostitis.  It  should  be  remembered  that  inflam- 
mation or  cicatrices  in  the  region  of  the  external  canthus  lead  to 
marked  edema  of  the  eyelids,  so  that  the  localization  of  the  painful 
spot  and  the  accompanying  resistance  alone  permits  a  diagnosis. 
Tumors  of  these  regions,  which  are  exceedingly  painful,  are  occa- 
sional. jSTeuroma  or  neurofibroma  are  to  be  expected.  Under  cer- 
tain circumstances  ulcerated  carcinomata  occur.  They  are  in- 
tensely painful  to  touch. 

The  pain  in  herpes  zoster  has  a  special  character.  It,  at  times, 
begins  a  few  days  before  the  appearance  of  an  eruption;  that  is, 
during  a  period  when  the  patient  complains  of  general  malaise. 
It  is  frequently  impossible  to  explain  such  attacks  of  pain  cor- 
rectly until  the  appearance  of  the  eruption  shows  the  nature  of 
the  disease.  The  pain  in  herpes  zoster  may  persist  with  the  same 
intensity  for  weeks  and  months  after  the  skin  lesions  are  healed 
and  the  accompanying  keratitis  and  iritis  have  subsided.  Nightly 
exacerbations  of  the  pain  are  not  rare.  The  pain  frequently  irra- 
diates into  other  branches  of  the  trigeminus  not  apparently  af- 
fected by  the  herpes.  Simultaneously  with  the  appearance  of  the 
intense  pain  there  arises  a  hypo-  or  even  anesthesia  of  the  skin  and 
superficial  parts  of  the  eye,  so  that  the  characteristic  symptom 
complex  of  anesthesia  dolorosa  may  appear.  The  sensibility  re- 
turns slowly.  Hyperesthesia  is  rare.  These  cases  of  herpes  zoster 
represent  the  projection  of  a  central  lesion  onto  the  peripheral 
endings  of  the  nerves.  Investigations  of  Barensprung,  Head  and 
Campbell,  and  Lauber  have  proved  that  the   primary  process   is 


320        SIGNIFICANCE    OF    PAIN   IN   DISEASE    OF    EYE 

localized  in  the  Gasserian  ganglion.  The  skin,  conjunctival  and 
corneal  chajiges  are  probably  to  be  regarded  as  trophic  lesions.  In 
some  cases  (Eisenlohr)  a  peripheral  neuritis  has  been  found,  so 
that  not  only  lesions  of  the  ganglion,  but  also  those  of  the  nerve 
are  to  be  considered  in  herpes  of  this  region. 

From  these  statements  it  can  be  seen  that  the  pain  in  herpes 
zoster  is  a  true  neuralgic  pain,  as  it  is  caused  by  a  lesion  of  the 
ganglion  or  of  the  peripheral  portion  of  the  nerve.  It  is  of  the 
character  of  acute  inflammatory  neuritis,  caused  by  some  toxic 
agent.  It  is  a  pathological  process,  occurring  in  the  sensory  gan- 
glia, analogous  to  that  in  the  motor  ganglion  cells  in  acute  anterior 
poliomyelitis  or  polioencephalomyelitis.  In  addition  to  the  virus, 
the  nature  of  which  is  as  yet  unkno^vn,  other  causes  of  herpes  zoster 
exist.  Such  are  traumatism,  tumors,  disease  within  the  cavernous 
sinus,  aneurysms  of  the  ophthalmic  artery,  pulsating  exophthalmos, 
poisoning  by  carbon  dioxid  and  arsenic.  All  of  these  affect  the 
fifth  nerve,  and  are  of  etiological  importance. 

A  disease  which  resembles  herpes  zoster  in  some  ways  is  neu- 
ralgic herpes  of  the  cornea  (herpes  cornse  neuralgicus  of  Schmidt- 
Kimpler).  This  is  a  periodically  appearing  affection,  often  re- 
curring at  the  same  hour  of  the  day.  The  attack  begins  by  pain 
in  the  supraorbital  branch  of  the  fifth  nerve,  and  is  characterized 
by  an  eruption  of  small  vesicles  in  the  distribution  area  of  this 
branch.    The  whole  attack  passes  off  in  a  short  time. 

The  pain  which  accompanies  a  febrile  herpes  of  the  cornea 
is  due  solely  to  the  epithelial  lesions,  and  does  not  show  the  typical 
neuralgic  character  of  the  two  affections  previously  considered. 

Several  other  forms  of  neuralgia  of  the  same  region  are  to  be 
distinguished  from  typical  trigeminal  neuralgia,  which  is  a 
persistent  and  very  torturing  disease.  They  show  the  same  symp- 
toms, but  are  secondary  affections  of  the  trigeminus.  Acute  neu- 
ralgias are  caused  by  inflammatory  conditions,  such  as  orbital 
periostitis,  empyema  of  the  accessory  sinuses  of  the  nose,  etc., 
and  occasionally  show  relapses.  Chronic  neuralgias  are  due  to 
tumor,  keloids,  or  to  chronic  forms  of  periostitis  and  empyema. 
ISTeuralgia  of  the  fifth  nerve  can  also  be  caused  reflexly  by  lesions 


LOCALIZATION    01    PAINS  321 

in  distant  regions,  as  by  caries  of  the  teeth  or  in  nasal  affections. 
These  can  mislead  the  patient,  as  well  as  the  physician.  It  is  con- 
sequently necessary,  in  cases  of  neuralgic  pain  of  the  fifth  nerve, 
to  examine  the  entire  distribution  area  of  this  nerve  for  causation 
lesions  before  making  a  diagnosis  of  idiopathic  or  primary  (essen- 
tial) neuralgia. 

A  diagnosis  of  neuralgia  is  generally  based  upon  the  tenderness 
of  the  nerve-stem  to  pressure.  In  the  investigation  of  a  case  of 
neuralgia,  pressure  should  be  applied  to  the  nerve  exits ;  i.e.,  over 
the  supraorbital  foramen,  the  infraorbital,  and  mental  foramina. 
This  excessive  tenderness,  accompanied  by  spontaneous  periodi- 
cally exacerbating  pain,  is  very  characteristic.  Tenderness  to  pres- 
sure is  absent  only  exceptionally  in  neuralgia.  This  symptom 
alone,  however,  is  not  sufficient  to  make  a  diagnosis  of  neuralgia, 
as  in  hysteria,  also,  the  brandies  of  the  fifth  nerve  are  frequently 
tender  to  pressure.  Furthermore,  tenderness  to  pressure  may  be 
a  symptom  of  a  general  polyneuritis  and  not  of  an  isolated  affec- 
tion of  the  trigeminus.  Especial  attention  should  be  called  to  the 
fact  that  neuralgic-like  pains  of  the  trigeminus  may  be  sympto- 
matic of  glaucoma,  or  they  may  be  precursors  of  this  disease, 
appearing  a  long  time  before  the  glaucoma  can  be  recognized. 

Another  type  of  periodically  returning  pain  in  the  trigeminus, 
though  generally  affecting  only  its  meningeal  branches,  is  hemi- 
crania,  or  migraine.  Here  the  so-called  scintillating  scotomata, 
with  their  characteristic  features,  are  diagnostic.  The  attack  be- 
gins ivith  eye  symptoms,  and,  during  this  period,  the  patient  no- 
tices the  scotomata  with  their  luminous  and  generally  moving 
margins.  These  attacks  are  then  followed,  as  a  rule,  by  intense 
unilateral  headache,  with  frequent  radiation  of  pain  throughout 
the  entire  fifth  nerve  area.  The  cause  of  the  phenomena  is  prob- 
ably a  vasomotor  disturbance,  which,  acting  upon  the  meninges,  is 
felt  in  the  peripheral  branches  of  the  nerve. 

A  very  rare  affection,  likewise  characterized  by  intense  liemi- 
crania,  is  a  recurring  third  nerve  palsy — ophthalmoplegic  mi- 
graine. Intense  hemicrania  introduces  the  attack,  to  which  ptosis 
and  almost  total  immobility  of  the  eye,  nausea,  or  vomiting  are 


322        SIGNIFICANCE    OF    PAIN    IN   DISEASE    OF    EYE 

added.  Such  attacks  persist  for  from  a  half  a  day  to  two  days 
or  more,  and  may  recur  at  irregular  intervals  of  a  few  weeks  or 
months.  Durino;  the  intervals  of  the  attack  the  third  nerve 
paralysis  recedes,  but  nuiy  not  completely  disappear. 

Surroundings  of  the  Eye.— Tender  pressure  points,  so  charac- 
teristic of  neuralgia,  may  exist  in  other  affections  of  the  surround- 
ings of  the  eye.  The  cause  of  indefinite  pain  in  the  head,  espe- 
cially of  dull  pain  in  the  forehead,  can  occasionally  be  found  by 
careful  palpation,  which  reveals  the  nerve  tenderness  at  a  certain 
place.  Tenderness  of  the  bone  to  percussion  and  tenderness  in 
the  region  of  the  trochlea  are  found  in  many  cases  of  acute  or 
chronic  affections  of  the  frontal  sinuses  and  the  anterior  ethmoid 
cells.  Thus,  one  may  be  guided  to  a  correct  diagnosis.  Such 
cases  can  be  differentiated  by  the  existence  of  delimited  sensitive 
areas  from  those  other  cases  where  the  bone  is  sensitive  through- 
out to  pressure  or  percussion,  and  at  the  same  time  is  diffusely 
thickened.  These  latter  symptoms  lead  to  the  diagnosis  of  perios- 
titis and  osteoperiostitis.  Indolent  thickenings  of  the  bone  are 
but  rarely  due  to  inflammation  (lues,  tuberculosis),  and,  as 
a  rule,  represent  tumor  or  protrusion  of  the  bones  by  meningo-  or 
meningoencephalocele. 

Conjunctiva  and  Cornea. — Pain  in  the  conjunctiva  and  its  cor- 
neal continuation  is  of  the  greatest  interest  to  the  oculist.  The 
abundant  end  ramifications  of  the  nerve  plexus  of  the  super- 
ficial layers  of  the  cornea  penetrate  as  far  as  the  basal  cells  of 
the  epithelium  and  explain  the  great  sensitiveness  of  this  organ, 
as  well  as  the  great  intensity  of  the  pain  in  superficial  lesions 
(erosions)  of  it.  The  conjunctiva  is  much  richer  in  nerves  than 
other  mucous  membranes  of  the  body.  Inflammatory  or  traumatic 
irritation  of  the  nerve  endings  in  the  conjunctiva  gives  rise  to 
very  severe  jDain,  alike  torturing  to  the  patient  and  difficult  for 
the  physician  to  abate.  Great  sensitiveness  to  thermic,  atmos- 
pheric, and  light  influences  is  present,  and  exposure  to  these  in- 
creases the  pain  to  the  highest  intensity.  While  there  is  not  the 
least  doubt,  so  far  as  thermic  and  atmospheric  stimuli  are  con- 
cerned, that  the  nerve  terminations  in  the  conjunctiva  and  cornea 


LOCALIZATION    OF   PAINS  323 

can  transmit  pain  stimuli  and  cause  suck  reflex  disturbances  as 
lachrymation  and  blepharospasm,  yet  light  can  also  give  rise  to 
painful  stimuli,  and  it  is  not  so  easy  to  determine  bow  it  acts  and 
causes  pain  in  corneal  and  conjunctival  lesions. 

It  is  a  fact,  however,  that  in  corneal  erosions  or  in  other  super- 
ficial lesions  of  the  cornea,  likewise  in  iritis,  there  exists  a  great 
sensibility  to  light  (photophobia),  even  when  the  patients  keep 
their  eyes  closed,  thus  excluding  atmospheric  and  thermic  in- 
fluences. 

In  iritis,  whether  primary  or  secondary  to  keratitis,  one  is 
inclined  to  attribute  the  pain  caused  by  light  to  reflex  contractions 
of  the  sphincter,  and  to  the  irritation  (on  pupillary  dilatation  or 
contraction)  of  the  sensory  nerves  in  the  stroma  of  the  iris.  But 
if  the  iris  is  normal,  and  its  contractility  is  suppressed  by  means 
of  a  mydriatic,  it  can  no  more  be  considered  as  a  source  of  pain, 
and  other  causes  of  the  corneal  irritation  to  light  (photophobia) 
must  be  sought.  Wilbrand  explains  photophobia  as  follows: 
"Exposure  to  light  leads  to  the  formation  of  products  of 
metabolism  in  the  piginent  of  the  retina;  if  the  forma- 
tion of  such  products  becomes  increased,  they  may  cause  pain  in 
the  ciliary  nerves  of  the  choroid,  which  contain  filaments  of  the 
fifth  nerve.  If  those  nerves  are  in  a  condition  of  pathological  irri- 
tation, even  small  quantities  of  these  products  of  katabolism  can 
cause  considerable  pain.  This  theory,  however,  does  not  explain 
why  the  instillation  of  cocain  into  the  conjunctival  sac,  in  quanti- 
ties which  can  act  only  upon  the  superficial  endings  of  the  nerves, 
can  in  many  cases  quite  suppress  the  photophobia.  This  would  be 
in  favor  of  an  explanation  which  attributes  light  sensibility  to  the 
endings  of  the  trigeminus  in  the  cornea  and  conjunctiva,  analogous 
to  the  direct  action  of  light  upon  the  iris.  This  theory  is,  how- 
ever, not  satisfactory. 

Hyperemia  of  the  conjunctiva,  infiltration  of  both  conjunctiva 
and  cornea,  detachment  of  the  corneal  epithelium  in  the  form  of 
vesicles  and  blebs  surely  lead  to  mechanical  and  possibly  also  to 
toxic  irritation  of  the  nerve  endings.  This  explains  why  the 
pain  is  so  very  severe  in  conjunctivitis  and  superficial  keratitis. 


324        SIGNIFICANCE   OF   PAIN   IN   DISEASE   OF   EYE 

Superficial  traumata,  which  expose  the  superficial  and  subepithe- 
lial nen'ous  plexi,  are  exceedingly  painful.  Deeper  wounds, 
which  penetrate  the  substance  of  the  cornea  and  sever  the  nerve- 
stem,  are  less  painful. 

In  an  irritative  condition  of  the  cornea  and  conjunctiva, 
tear-secretions  retained  in  the  conjunctival  sac  can  cause  consider- 
able complaint.  The  accumulation  of  tears  in  the  conjunctival 
sac,  when  an  eye  is  kept  under  a  bandage  after  an  operation,  may 
cause  great  discomfort,  and  even  pain,  which  can  be  instantane- 
ously relieved  by  removing  the  bandage  and  opening  the  eye. 
Small  quantities  of  mucus  or  muco-pus,  on  the  surface  of  the  eye, 
are  perhaps  the  cause  of  the  sensation  of  a  foreign  body  in  con- 
junctivitis. 

In  cases  of  gonorrheal  or  dijihtheritic  conjunctivitis  the  edema 
of  both  conjunctiva  and  lids  may  lead  to  such  stretching  of  the  lid 
that  it  can  be  the  source  of  pain.  However,  this  is  easily  re- 
moved by  simj)le  canthotomy. 

After  foreign  bodies  of  the  cornea  or  conjunctiva  have  been 
removed  the  sensation  of  their  presence  frequently  persists  for  a 
few  hours  and  disappears,  together  with  the  subsidence  of  hyper- 
emia and  the  reparation  of  the  tissue  lesions.  Observations  of 
this  kind  prove  tliat  both  hyperemia  and  the  pressure  of  an  almost 
imperceptible  exudate  are  able  to  irritate  the  nerve  termination  to 
a  high  degree  and  cause  pain. 

In  erosions  of  the  cornea  the  j^ain  often  has  a  recurring  char- 
acter. According  to  von  Reuss,  two  types  of  this  affection  can  be 
distinguished.  In  the  first  slight  pain  appears  on  first  opening 
the  lids  after  sleep,  or  after  they  have  been  kept  closed  for  a  long 
time.  This  soon  ceases.  In  the  second  type,  after  a  period  of 
apparent  health,  attacks  of  pain  occur,  having  the  same  char- 
acter and  intensity  as  those  following  the  original  trauma.  They 
are  caused  by  a  plainly  visible  loss  of  epithelium  in  the  same  place 
where  the  primary  injury  had  originally  led  to  the  loss  of  sub- 
stance. Both  types  of  the  affection  are  the  consequences  of  an 
abnormal  condition  of  the  epithelium  established  by  the  trauma. 
Close  examination  of  the  cornea  with  a  lens,  or  by  the  ophthalmo- 


LOCALIZATION    OF    PAINS  325 

scope,  show  minute  ojDacities  in  the  epithelium.  In  the  first  group 
of  cases  the  corneal  epithelium,  which  during  the  night  is  in  close 
contact  with  the  tarsal  conjunctival  epithelium,  sticks  fast  to  the 
latter  and  is  torn  off  when  the  eye  is  opened.  In  the  second  group 
of  cases  (the  recurring  erosion  in  a  strict  sense)  the  epithelium 
degenerates,  is  cast  off,  and  exposes  the  nerve  plexus  lying  in 
the  superficial  layers  of  the  cornea. 

The  pain  associated  with  corneal  herpes  and  punctate  superfi- 
cial dendritic  and  stellate  keratitis  is  due  to  similar  causes.  Cor- 
neal ulcers  of  various  types  all  expose  the  nerve  plexus  of  the 
cornea,  and  can,  therefore,  cause  more  or  less  pain.  Tlie  pain 
becomes  more  intense  when  the  exposed  nerves  are  irritated  by 
the  moving  lids.  For  that  reason  a  bandage  is  applied  to  prevent 
the  movement  of  the  lids,  and  thus  to  diminish  the  pain.  It 
cannot  relieve  it  completely,  as  the  infiltration  of  the  .tissues  exer- 
cises pressure  upon  the  nerves  and  stretches  them.  Toxins  pro- 
duced by  bacteria  also  cause  painful  irritation  of  the  corneal 
nerves.  Sudden  pain  arising  in  a  case  of  ulcerating  keratitis 
frequently  indicates  perforation  of  the  ulcer.  The  chief  cause 
of  pain  in  perforation  of  the  cornea  ia  the  mechanical  irritation 
of  the  iris.  If  the  iris  prolapses  and  cicatrizes,  sudden  and  in- 
tense pain  may  again  arise.  This  is  a  symptom  of  secondary 
glaucoma.  The  severe  pain  which  frequently  accompanies  deep 
keratitis  is  largely  due  to  a  concomitant  iritis. 

Referred  pain  is  also  present  if  the  ulcer  extends  into  the 
deeper  layers  of  the  cornea.  The  area  of  reference  is  in  the  fronto- 
nasal area,  and  also  to  some  extent  in  the  midorbital  (Head).  This 
referred  pain  is  probably  due  to  a  deepening  of  the  anterior  cham- 
ber. Should  a  true  cyclitis  be  present,  the  pain  is  referred  fur- 
ther to  the  side  in  the  forehead  than  in  corneal  ulceration,  the 
midtemporal  area  being,  as  a  rule,  concomitantly  involved  with 
the  midorbital.     (See  page  291.) 

The  Iris  and  Ciliary  Body.  — The  existence  of  a  dense  nervous 
plexus  in  the  iris  and  the  ciliary  body  fully  explains  the  severe 
pain  found  in  diseases  of  these  parts.  The  specific  etiology  of 
iritis  and  iridocyclitis  is  also  a  factor  in  the  origin  of  iritic  and 


326        SIGNIFICANCE    OF    PAIN   IN   DISEASE   OF    EYE 

cyclitic  pain.  Its  importance,  however,  should  not  be  exagger- 
ated. The  pain  is  frequently  continuous,  and  may  be  localized  in 
the  eyeball  itself,  or  in  the  surrounding  bones,  even  in  the  entire 
half  of  ^the  head  corresponding  to  the  affected  eye.  As  in  many 
other  diseases,  so  in  iritis  and  iridocyclitis  exacerbation  of  the  pain 
is  observed  toward  the  end  of  the  night  or  in  the  early  morning. 
This  is  not  only  characteristic  of  syphilitic  affections,  but  occurs 
in  the  same  way  in  rheumatic  and  traumatic  cases  of  iritis.  In 
rheumatic  iritis,  more  often  than  in  those  due  to  other  causes, 
severe  pain  during  the  night  is  a  sign  of  a  relapse  or  of  an  exacer- 
bation of  the  inflammatory  trouble.  Examination  of  the  eye  the 
next  morning  shows  fresh  fibrinous  exudate  in  the  anterior 
chamber,  or  the  presence  of  a  fresh  hyperemia.  Such  acute  at- 
tacks of  pain  are  usually  of  short  duration.  Metastatic  gonorrheal 
iritis  is  a  type  of  iritis  which  causes  the  most  intense  and  obstinate 
pain.  The  referred  pain,  as  a  rule,  is  in  the  frontotemporal, 
maxillary  and  temporal  areas.  Should  the  tension  in  the  vitreous 
chamber  rise,  the  pain  has  a  tendency  to  be  referred  further  back, 
and  also,  in  some  cases,  the  teeth  of  the  upper  and  even  of  the 
lower  jaw  may  become  painful  and  very  sensitive  to  pressure. 

Rest  in  bed,  atropin,  warm  applications,  dionin,  and  diapho- 
resis are  serviceable  for  all  forms  of  iritis.  If  the  pain  is  very 
intense  aspirin,  pyramidon,  or  morphin  must  be  given,  and  even 
these  analgesics  may  prove  insufficient  to  relieve  the  pain.  In 
chronic  iritis  and  iridocyclitis  the  pain  is  generally  very  moder- 
ate. Circumscribed  areas  in  the  region  of  the  ciliary  body,  which 
are  tender  to  pressure,  can  be  sometimes  detected.  They  probably 
correspond  to  small  inflammatory  foci  which  do  not  cause  any 
other  clinical  symptoms.  It  is  important  to  ascertain  their  pres- 
ence, as  they  direct  attention  to  the  possible  recurrence  of  the 
disease. 

A  sudden  exacerbation  of  pain  in  an  acute  or  a  chronic  iritis 
should  always  arouse  the  suspicion  that  a  secondary  glaucoma  is 
developing.  The  pain  caused  by  such  an  attack  of  secondary  glau- 
coma can  reach  the  highest  possible  degree.  The  increase  of  intra- 
ocular tension  is  diagnostic  for  acute  glaucoma,  although  the  dif- 


LOCALIZATION    OF    PAINS  327 

ferential  diagnosis  between  a  primary  and  a  secondary  glaucoma 
may  be  very  difficult,  especially  when  the  cornea  is  dull  and 
opaque. 

A  painful  condition,  which  closely  resembles  iritis,  and  which 
is  in  direct  contrast  to  glaucoma,  is  an  acute  hypotonia  of  the 
globe,  complicating  detachment  of  the  retina.  Hypotonia  of  this 
kind  can  exist  without  any  pain.  In  very  pronounced  and  acute 
cases,  however,  pain  appears.  To  this  subjective  symptom  there 
corresponds  an  objective  change,  consisting  of  a  slight  ciliary  in- 
jection of  the  globe,  a  deepening  of  the  anterior  chamber  and  a 
tremulous  condition  of  both  iris  and  lens.  The  vitreous  is  gener- 
ally very  turbid,  and  permits  only  indistinct  recognition  of  the 
increase  of  a  preexisting  or  the  first  appearance  of  a  retinal  de- 
tachment which  previously  had  not  existed.  The  pain,  as  a  rule, 
is  mild  and,  together  with  other  symptoms,  slowly  disappears. 

In  the  course  of  retinal  detachment  there  also  occurs  another 
painful  process,  i.e.,  an  iritis,  which,  similarly  to  the  detachment, 
is  a  consequence  of  the  high  myopia.  If  pain  appears  in  the  eye 
affected  with  posterior  staphyloma  iritis  might  be  present.  Such 
myopic  iritis  seldom  appears  in  posterior  staphyloma  without  in- 
volvement of  the  retina,  and  may  be  a  precursory  symptom  of  this 
grave  affection. 

Sclerotic  Coat. — Areas,  tender  to  pressure,  similar  to  those 
previously  described  as  occurring  in  chronic  iritis,  but  correspond- 
ing to  hyperemic  and  swollen  areas  of  the  sclerotic,  are  characteris- 
tic for  scleritis.  This  affection  may  cause  violent,  spontaneous 
pain,  but  may  also  be  absolutely  indolent.  It  is  not  exactly  known 
why  some  cases  of  scleritis  are  very  painful  and  others  are  not. 
This  certainly  does  not  depend  upon  the  etiology,  as  both  forms 
may  be  caused  by  the  same  etiological  factors.  Anatomical  inves- 
tigation (Oatman)  may  explain  it.  In  some  cases  the  ciliary 
nerves,  as  they  pass  through  the  foci  of  the  scleritis,  remain  nor- 
mal; while  in  others  they  are  infiltrated  by  leukocytes.  The  in- 
filtrated nerves  show  the  anatomical  picture  of  a  neuritis,  and 
this  is  probably  the  cause  of  the  pain. 

Inflammatory  foci  of  the  scleritis  may  be  invisible,  on  account 


328        SIGNIFICANCE    OF   PAIN   IN   DISEASE    OF    EYE 

of  chemosis.  If  such  is  the  case,  palj)ation  of  the  globe  will  easily 
disclose  the  situation  of  the  sclerotic  foci.  A  sclerotic  iufiltration, 
situated  under  one  of  the  muscles,  or  at  a  muscular  insertion,  will 
be  irritated  by  contraction  of  the  muscles  and  cause  pain  in  move- 
ments of  the  eye. 

Similar  pain  following-  eye  movements  may  be  the  sign  of 
rheumatism  of  an  eye-muscle.  The  diagnosis  of  this  condition  is 
based  on  the  subjective  symptom  of  pain  without  any  visible 
changes.  Diplopia  as  a  sign  of  impaired  movement  is,  however, 
not  present  in  these  cases  of  rheumatism. 

Choroid,  Retina  and  Optic  Nerve. — Inflammation  of  the  inter- 
nal membranes  of  the  eye,  choroid  and  retina,  as  well  as  inflam- 
mation of  the  optic  nerve,  generally  does  not  give  rise  to  pain. 
Acute  retrobulbar  neuritis  is  an  exception.  Dull  pain  in  the 
orbit,  increasing  on  extreme  or  violent  movement  of  the  eye,  or 
on  pressure  upon  the  globe,  and  associated  with  rapidly  increasing 
amblyopia  and  negative  ophthahiioscopic  findings,  is  the  chief 
symptom  upon  wliich  the  diagnosis  is  founded.  A  similar  deep 
pain  on  pressure  occurs  in  posterior  scleritis,  which  sometimes 
shows  an  intermittent  exophthalmos,  and  also  in  periostitis  or  em- 
pyema of  the  posterior  ethmoidal  cells. 

Bulb.- — Pain  originating  in  phthisic  eyes  deserves  especial 
attention  and  may  arise  from  different  causes.  In  most  cases  it 
is  due  to  increase  of  pressure  of  the  process  which  originally 
caused  the  phthisis,  and  is  of  the  greatest  importance,  because  a 
reappearance  of  a  previous  inflammation  may  produce  a  sympa- 
thetic affection  of  the  other  eye.  Therefore,  it  cannot  be  exj^ressed 
too  strongly  that  all  phthisical  globes  which  cause  spontaneous  pain 
ought  to  be  removed. 

Up  to  the  present  time  no  symptom  is  kno\vn  jjermitting  a 
differential  diagnosis  between  an  eye  aj)t  to  induce  sympathetic 
ophthalmia  from  those  which  are  harmless.  Great  attention  must 
be  given  to  the  other  eye.  Dull  pain  in  the  healthy  eye  may  be 
the  first  symptom  of  a  sympathetic  trouble.  The  suspicion  of  a 
beginning  process  of  this  nature  will  be  aroused,  especially  by  the 
appearance  of  photophobia,  ciliary  hyperemia,  and  diminution  of 


LOCALIZATION    OF    PAINS  329 

the  range  of  accommodation.  These  symptoms,  which  have  heen 
described  as  sympathetic  irritations,  may  precede  the  outbreak  of 
an  iridocyclitis  for  a  varying  period  of  time.  Sympathetic 
ophthalmia  may  also  begin  without  irritative  symptoms. 

Sunken  globes  may  become  painful  also  from  other  reasons. 
Such  are  ossification  of  the  choroid,  which  causes  pressure  upon 
the  branches  of  the  ciliary  nerves,  and  folding  of  the  sclerotic, 
which  acts  in  the  same  manner.  Attention  may  be  directed  to 
the  fact  that,  even  after  the  enucleation  of  a  globe,  the  trunk  of 
the  optic  nerve  or  its  surroundings  may  be  very  painful  to  pres- 
sure, and  is  an  indication  for  the  resection  of  these  parts  in  order 
to  enable  the  patient  to  wear  a  shell.  The  cause  of  this  pain  is 
a  neuroma  of  the  ciliary  nerves. 

Glaucoma. — The  most  violent  pain  which  can  exist  in  eye  dis- 
eases is  that  found  in  acute  glaucoma.  The  increase  of  intraocular 
tension  and  the  consecutive  pressure  upon  the  nerves  in  all  the 
tissues  of  the  globe  are  given  as  the  explanation  of  this  pain. 
Radiation  of  pain  into  different  distributing  areas  of  the  trigemi- 
nus is  quite  frequent,  and  has  caused  the  condition  to  be  mistaken 
for  a  neuralgia,  a  hemicrania,  a  toothache,  or,  when  vomiting  is 
present,  even  for  a  meningitis.  It  is  unnecessary  to  analyze  the 
nature  of  an  acute  attack  of  glaucoma.  It  should  be  remembered 
that  inexplicable  pain  in  the  first  branch  of  the  fifth  nerve  is 
frequently  a  symptom  of  glaucoma ;  either  prodromal  or  the  devel- 
oped disease.  No  doubt  neuralgia  may  precede  the  outbreak  of  an 
acute  glaucoma  by  months  or  years.  This  pressure  may  be  reduced 
(with  consequent  relief  of  pain)  by  miotics.  The  diminution  of 
intraocular  pressure  due  to  miotics  may  be  considerably  enhanced 
by  the  use  of  one  per  cent,  solution  of  morphin,  used  as  a  collyrium 
simultaneously  with  the  miotics.  Eserin  is  excellent  in  subduing 
pain  caused  by  glaucoma.  If,  however,  it  is  instilled  into  a  nor- 
mal eye  it  is  liable  to  cause  considerable  pain.  This  is  due  to 
the  compression  of  the  nerve  fibers  by  the  tonic  contraction  of  the 
sphincter  of  the  pupil.  This  pain  may  be  quickly  removed  by 
the  use  of  a  mydriatic. 

Iridectomy  and  other  operations  devised  to  replace  iridectomy 


330        SIGNIFICANCE    OF    PAIN   IN   DISEASE    OF    EYE 

alleviate  the  pain  rapidly  when  they  reduce  the  ocular  tension.  If 
after  an  operation  for  glaucoma  intense  pain  arises,  or  an  increase 
of  pressure  is  noted,  it  is  a  symptom  indicating  the  malignancy 
of  the  glaucoma,  and  forebodes  the  loss  of  the  eye.  If  the  eye 
is  blind  and  painful  from  glaucoma  one  may  attempt  to  relieve 
the  pain  by  anti-glaucomatous  operations,  if  they  are  possible; 
otherwise,  there  remains  only  opticociliary  neurotomy  or  enuclea- 
tion of  the  globe.  The  operation  first  referred  to  is  a  dangerous 
undertaking,  as  its  results  are  doubtful,  and  in  many  cases  it 
must  be  followed  by  enucleation. 

Panophthalmitis. — Pain  in  panophthalmitis  is  caused  in  a 
similar  manner  to  that  of  glaucoma.  The  presence  of  a  focus 
of  purulent  inflammation  in  the  globe,  with  the  consequent  pres- 
sure, explains  the  painfulness  of  the  disease.  That  the  simple 
opening  of  the  globe  by  incision  or  spontaneous  perforation  at 
once  considerably  relieves  the  pain  proves  that  increase  of  pressure 
due  to  the  purulent  exudation  plays  a  great  part  in  the  etiology 
of  pain  in  panophthalmitis. 

Asthenopic  Disorders. — An  entirely  different  group  of  painful 
conditions  is  met  with  in  the  asthenopic  disorders  and  the  closely 
related  cases  of  eye-strain.  In  both  accommodative  and  muscular 
asthenopias,  whether  the  latter  be  caused  by  exophoria  or  insuffi- 
ciency of  convergence,  the  phenomena  are  blurring  of  objects  and 
a  dull  pain  in  the  forehead.  This  is  accompanied  by  a  feeling  of 
heaviness  and  pressure  in  the  eyelids,  lacrymation  and  a  sensation 
of  heat  in  the  eyes.  If,  in  spite  of  these  symptoms,  the  eyes 
are  used  for  work,  headache  may  appear  and  continue  even  during 
the  next  day.  Asthenopic  disorders  manifest  themselves,  as 
a  rule,  in  the  late  afternoon  or  in  the  evening,  when  the 
muscular  apparatus  is  tired  by  the  day's  work.  Proper  glasses  or 
prisms  can  totally  suppress  the  trouble,  or  at  least  alleviate  it  con- 
siderably. In  muscular  asthenopia  stereoscopic  exercises  can  also 
be  of  benefit. 

How  far  a  low  degree  of  astigmatism  may  cause  trouble  is  not 
quite  determined.  Most  of  the  European  oculists  are  sceptical  in 
regard  to  this  question,  whereas  English  and  American  oculists, 


LOCALIZATION    OF    PAINS  331 

especially  the  latter,  attribute  a  gTeat  number  of  subjective  dis- 
orders to  uncorrected  or  insufficiently  corrected  astigmatism.  They 
also  have  created  and  developed  the  term  "eye-strain,"  to  which 
disturbances  in  all  parts  of  the  organism  are  ascribed.  Disturb- 
ances due  to  hyperphoria  are  les$  frequent  than  simple  asthenopic 
phenomena,  and  differ  from  muscular  asthenopia  in  exophoria,  in 
that  they  trouble  the  patient  not  only  in  close  work,  but  cause 
incessant  aching.  The  prescription  of  corresponding  prisms  with 
the  apices  upward  and  downward  suppresses  such  disorders 
promptly. 

To  Bielschowsky  we  owe  the  knowledge  of  a  rare  group  of 
painful  disturbances  related  closely  to  asthenopia.  This  author 
has  discovered  cases  of  disturbed  innervation  of  binocular  vision 
leading  to  considerable  subjective  disturbances  and  simulating 
squints.  Their  treatment  either  by  operation  or  drugs  is  rarely 
successful. 

In  hyperopics  the  over-strained  accommodation  leads  to  asthen- 
opia. Disturbances  caused  by  straining  of  the  accommodation 
do  not  occur  in  myopics,  who,  nevertheless,  experience  disagree- 
able sensations.  Myopics  of  the  middle  and  higher  gTades  fre- 
quently complain  of  pain  in  their  eyes  when  they  use  them  for 
close  work.  This  pain,  which  is  intermittent  but  not  severe,  may 
yet  be  very  troublesome  to  sensitive  and  neurasthenic  individuals. 

'No  generally  accepted  explanation  of  this  kind  of  pain  exists, 
but  it  would  seem  quite  plausible  to  connect  it  with  the  process  of 
stretching  of  the  sclerotic,  which  may  also  affect  the  nerves  lying 
in  the  sclera.  This  pain  cannot  be  influenced  by  the  wearing  of 
correcting  glasses,  or  by  the  extractions  of  the  lens  for  removal 
of  the  myopia. 


CHAPTER  XVI 

PAIN    IN    DISEASES    OF    THE    EAE  i 

It  passes  as  current  fact  among  the  laity  that  ear  pains  can 
scarcely  be  surpassed  in  severity  by  any  pain  elsewhere  in  the 
body.  Relief  may  be  secured  from  pain  occurring  in  any  part  of 
the  external  or  middle  ear,  but  not  from  pain  of  labyrinthine 
origin. 

External  Ear. — Trauma  of  the  external  ear  is  scarcely  more 
painful  than  trauma  in  other  parts  of  the  body,  but  it  may  be 
followed  by  two  troublesome  conditions,  namely,  othematoma  and 
perichondritis.  Othematoma  is  an  exudate  of  serous,  bloody  fluid 
between  the  cartilage  and  perichondrium  of  the  ear.  It  results 
from  a  blow,  especially  one  from  a  fist.  Consequently,  we  find 
it  frequently  among  prizefighters,  and  perhaps  most  frequently 
among  the  Japanese  wrestlers,  because  they  use  the  head  and  neck 
against  the  head  of  an  opponent,  and  in  this  way  the  ear  often 
becomes  subject  to  very  great  pressure,  giving  rise  to  the  above- 
mentioned  exudate.  It  also  is  frequently  seen  among  patients  suf- 
fering from  acute  mental  disturbances. 

The  pain  in  hematoma  is  usually  trifling.  It  is  mostly  of  a 
dull,  aching  character,  worse  at  night.  If,  however,  the  othema- 
toma becomes  infected  through  unskilful  surgery,  a  very  painful 
perichondritis  may  follow. 

Such  a  perichondritis  arises  sometimes,  also,  after  a  radical 
operation,  as  a  result  of  infection  of  the  cartilage.  This  cannot 
always  be  avoided  in  plastic  work  upon  the  external  ear.  If  the 
bacillus  pyocyaneus  is  present  in  the  middle  ear  secretion,  this 
germ,  which  has  a  fondness  for  attacking  cartilage,  may  bring 

1  By  Dr.  Euttin,  assistant  in  the  Ear  Clinic  of  the  University  of  Vienna. 
332 


EXTERNAL    AUDITORY    CANAL  333 

about  a  perichondritis.  In  fact,  one  can  always  grow  the  bacillus 
pyocyaneus  in  pure  culture  from  the  perichonclritic  secretion. 
Such  a  perichondritis  advances  very  slowly,  and  lasts  about 
four  weeks,  when  the  disease  has  reached  its  highest  point.  The 
suppuration  then  ceases,  and  the  cartilage  begins  to  shrink.  Un- 
fortunately, early  and  energetic  incision  does  not  shorten  its 
course.  During  the  period  of  development,  to  the  beginning  of 
the  shrinking  of  the  cartilage,  extraordinarily  severe  pains  exist. 
It  often  requires  much  persuasion  to  convince  the  patient  that 
this  distressing  condition  is  not  dangerous. 

Of  the  tumors  of  the  external  ear,  carcinoma  and  sarcoma 
sometimes  give  rise  to  severe  pains,  but  they  often  run  a  painless 
course.  The  same  is  true  of  the  inflammatory  granulomata  of 
lupus  and  lues,  in  which  the  slight  pain  may  be  completely  over- 
shadowed by  the  itching. 

Pain  of  the  external  ear  due  to  frostbite  is  especially  note- 
worthy. It  is  peculiar  in  that  it  is  likely  to  recur  with  every 
return  of  cold  weather.  The  previously  frozen  parts  often  begin 
to  be  painful  again,  even  with  a  moderate  fall  of  temperature. 

A  very  painful  disturbance  in  the  pinna,  which  is,  to  be  sure, 
only  a  symptom  of  another  disease,  is  herpes.  The  pain  begins 
even  before  the  appearance  of  the  herpetic  vesicles,  and  continues 
usually  until  they  vanish.  Gouty  nodules,  which  have  a  prefer- 
ence for  the  helix  margin  of  the  pinna,  may  be  the  cause  of 
pains  which  are  of  a  very  unstable  and  changing  character,  a 
peculiarity  of  gouty  nodules  in  general. 

External  Auditory  Canal.— The  external  canal,  with  its  nu- 
merous hairs  and  glands,  is  directly  predisposed  to  furunculosis. 
The  frequency  of  middle-ear  suppuration,  and  the  circiunstances 
that  such  a  condition,  after  only  a  short  existence,  in  most  cases 
shows  a  secondary  infection  with  pyogenic  staphylococcus,  carries 
with  it  the  probability  that  during  the  necessary  cleaning  manipula- 
tions of  patient  or  physician  the  liair  follicles  become  inoculated, 
a  procedure  which,  according  to  the  researches  of  Schimmelbusch, 
Garre  and  others,  brings  about  furunculosis  with  tolerable  cer- 
tainty. 


334  PAIN   IN    DISEASES    OF   THE    EAR 

Furuncle  of  the  external  canal  manifests  itself  through  a 
special  painfulness,  because  the  pus,  on  account  of  the  closely 
woven,  subcutaneous,  connective  tissues,  is  held  under  a  high 
degree  of  pressure.  These  pains  are  of  a  boring,  sticking,  throb- 
bing nature,  and  radiate,  by  preference,  toward  the  teeth.  There- 
fore, the  patient  can  take  only  a  very  limited  amount  of  nourish- 
ment, since  every  movement  of  the  mouth  increases  the  pain. 
This  is  due  to  the  fact  that  the  head  of  the  inferior  maxilla  lies 
against  the  anterior  wall  of  the  external  auditory  canal,  and 
movements  of  the  jaw  joint  are  accompanied  by  movements  of 
the  adjacent  aural  tissues.  The  pain  usually  subsides  with  the 
rupture  of  the  furuncle,  or  with  its  opening. 

The  pain  of  diffuse  inflammation  in  the  external  canal,  the 
so-called  otitis  externa  diffusa,  is  of  longer  duration,  and  much 
less  certainly  influenced  by  operation. 

ForeigTi  bodies  in  the  external  auditory  canal  cause  pain 
usually  only  by  penetration,  by  wounds  brought  about  by  unskil- 
ful attempts  to  dislodge  them,  or  by  the  swelling  or  growing  of 
the  foreign  body  in  the  ear.  Peas,  beans  and  fruit  kernels 
remaining  for  some  time  in  the  canal  swell,  and  cause  a 
very  noticeable  pressure  upon  the  canal  wall,  thereby  producing 
more  or  less  pain.  The  larvse  of  the  large  meat-fly  ("blue-bottle 
fly"),  developing  from  eggs  laid  in  the  canal,  often  attain  great- 
ness, both  in  number  and  in  size.  They  may  cause  such  pressure 
upon  the  external  canal  that  it  becomes  widened  to  the  breadth  of 
a  finger.  Since  these  maggots  are  provided  with  sharp  hooks  at 
the  ends  of  their  bodies,  and  seek  to  attach  themselves  by  sticking 
these  hooks  into  the  skin,  the  pain  which  they  produce  is  extraor- 
dinarily severe.  This  becomes  still  greater,  because  the  worm 
masses  are  always  in  motion,  and  consequently  the  pain  is  of  a 
continuous,  changing,  undulating  character.  I  have  observed  such 
a  case,  in  which  twenty-six  maggots  had  brought  about  a  consider- 
able widening  of  the  canal,  with  very  intense  pain. 

In  lesions  of  the  middle  ear  the  patient  assumes  a  position  in 
which  the  ear  of  the  affected  side  rests  in  the  palm  of  a  supporting 
hand,  the  elbow  resting  on  a  table,  as  is  illustrated  in  Fig.  80, 


MIDDLE-EAR    DISEASE 


335 


Tympanum. — Pains  may  originate  in  the  drum  membrane. 
One  often  speaks  here  of  a  myringitis  bullosa.  This  is,  however, 
not  a  bacterial  invasion,  but  is  only  a  herpes  of  the  drum.  Bac- 
teriological examination  in  large  numbers  of  such  cases  showed 
the  vesicles  to  be  sterile.  The  sudden  beginning  of  the  pain  is 
very  characteristic  for  myringitis.  Often  the  patient  is  awakened 
at  night  by  a  sudden,  severe,  sticking  pain  in  an  ear  previously 
entirely  sound.  The  pain 
lasts  as  long  as  the  vesicle 
remains,  but  ceases  just  as 
suddenly  as  it  began. ^ 

In  lesions  of  the  exter- 
nal meatus  from  the  tym- 
panum outward  the  pain  is 
localized  to  the  diseased 
area,  but  from  the  drum  in- 
ward the  pain  is,  as  a  rule, 
referred  to  a  distant  area, 
the  most  common  reference 
area  being  the  hyoid,  which 
has  two  points  of  maximum 
tenderness,  the  first  in  the 
meatus  and  the  second  just 
behind  the  angle  of  the  jaw. 
These  areas  are  also  asso- 
ciated with  the  tonsil,  the 
posterior  teeth  of  the  lower 
jaw,  and  the  lateral  aspects 
of  the  tongue  (Head).  When  the  tension  in  the  middle  ear  is 
raised  pain  may  also  be  referred  to  the  vertical  and  parietal  area 
of  the  scalp.     (See  pages  293  and  294.) 

Middle-ear  Disease. — Acute  Otitis  Media. — Most  marked 
are  the  pains  of  acute  middle-ear  inflammation.  Here  they  are 
not  limited  to  the  membrana  tympani,  and  are  most  severe  until 

'  Hunt,  of  New  York,  has  shown  that  this  type  of  herpes  is  usually 
associai^ed  with  disease  of  the  geniculate  ganglion. 


Fig.  80. — Postuee  Assumed  in  Earache 


336  PAIN    IN    DISEASES    OF    THE    EAR 

perforation  of  the  drum  takes  place.  We  must,  however,  differ- 
entiate two  kinds  of  acute  otitis,  namely,  that  caused  by  capsulated 
bacilli,  and  that  caused  by  noncapsulated  bacilli.  While  in  the 
first  type  the  pain  is  usually  trifling  in  nature,  and  only  "stick- 
ing" in  the  first  day  of  the  disease,  as  in  middle-ear  catarrh,  the 
second  type,  caused  by  noncapsulated  cocci,  calls  forth  the  most 
capricious  and  troublesome  symptoms.  The  pains  begin  with 
moderate  intensity  and  increase,  within  two  or  three  days,  to 
quite  unusual  severity.  They  are,  as  a  rule,  of  a  boring,  sticking  or 
tearing  nature,  and  reach  the  greatest  degree  when  the  drum  mem- 
brane becomes  deep  red,  shoAvs  no  details,  and  is  nearly  ready  to 
rupture  at  some  markedly  bulging  spot.  After  rupture  the  pain 
for  the  most  part  ceases.  Obviousl}'  one  can  shorten  the  patient's 
sufferings  by  carrying  out  artificial  rupture  of  the  drum  through 
incision  (paracentesis).  It  must  be  regarded  as  an  unfavorable 
sign,  if,  after  perforation  of  the  drum,  the  pains  do  not  immedi- 
ately subside.  In  such  cases  the  mastoid  process  is  likely  to  be 
included,  and  if  this  comes  to  pass  spontaneous  pains  of  greater 
or  less  severity  manifest  themselves.  However,  this  symptom  may 
be  completely  lacking,  or  may  only  be  elicited  by  pressure,  either 
upon  the  mastoid  tip  or  over  the  antrum,  in  which  latter  case 
the  mastoid  cells  are  undoubtedly  involved.  To  be  sure  the  prop- 
agation of  the  inflammation  to  this  degree  must  depend  upon  the 
anatomical  structure  of  the  mastoid  process.  A  pneumatic  mas- 
toid is  always  affected  in  the  beginning  of  an  acute  otitis,  and 
this  is  the  reason  why  tenderness  at  the  tip  in  such  cases  is  so 
frequently  seen.  But  this  inflammation  may  at  any  stage  retro- 
gress without  going  on  to  suppuration  and,  therefore,  in  the  begin- 
ning of  an  acute  otitis  this  symptom  has  no  pathognomonic  sig- 
nificance. If,  however,  the  tenderness  or  the  spontaneous  pains 
last  a  relatively  long  time,  or  if,  after  having  once  vanished, 
they  reappear,  then  it  is  probable  that  we  have  to  do  with  an 
abscess  in  the  mastoid  process,  and  in  this  regard  the  symptom 
becomes  of  great  importance  with  respect  to  operative  inter- 
ference. 

Cheonic  middle-eae,  discharge  causes,  as  a  rule,  no  pain; 


MIDDLE-EAR   DISEASE  337 

but  pain  may  arise,  of  course,  as  a  result  of  an  acute  exacerba- 
tion, or  if  the  perforation  in  the  drum  is  so  small  that  opportunity 
is  given  for  retention  of  pus.  Sometimes  chronic  middle-ear  sup- 
puration, which  otherwise  would  give  no  pain,  is,  when  accom- 
panied by  cholesteatoma,  subject  to  manifestation  of  severe  pain. 

Complications  of  Middle-eae  Disease. — If  acute  or 
chronic  middle-ear  suppuration  becomes  complicated  by  extension 
of  the  inflammation  to  neighboring  regions,  then  the  pain  thus  pro- 
duced is  usually  quite  sigiiificant,  especially  if  suppuration  takes 
place  in  the  mastoid,  whereby  the  mastoid  cells  are  broken  down 
and  the  excavated  interior  of  this  bone  becomes  filled  by  pus, 
which,  through  gi-adual  accumulation,  exerts  great  pressure.  If 
this  pus  breaks  externally  through  the  bone  cortex,  it  can  dissect  the 
periosteum  free  from  the  bone  to  a  very  gi'eat  extent.  We  then 
find  a  large  swelling  behind  the  ear,  which  is  covered  by  a  much- 
reddened,  very  tense  epidermis,  giving  rise  to  gi-eat  pain.  This 
swelling  may  become  so  great  that  the  entire  half  of  the  head  is  in- 
volved, especially  in  badly  neglected  cases.  This  subperiosteal  ab- 
scess formation  is  very  frequent  in  children,  because  the  pus  passes 
through  the  open  fissura  mastoidea  in  a  very  short  time,  and  then 
lies  directly  under  the  periosteum ;  but  here,  on  the  other  hand, 
instead  of  producing  pain,  the  pain  may  be  actually  lessened 
after  penetration  to  the  periosteum  for  a  time,  at  least,  through 
relief  of  pressure  within  the  mastoid  shell. 

If,  however,  the  pus  burrows  inward,  the  dura  becomes  ex- 
posed through  destruction  of  bone,  either  in  the  posterior  or  mid- 
dle fossa,  according  to  the  direction  which  the  destructive  process 
takes.  The  tough  dura  and,  in  the  posterior  fossa,  the  sinus  lat- 
eralis are  fairly  resistant  structures,  and  may  often  be  sur- 
rounded by  pus  for  a  long  time  without  becoming  especially  af- 
fected. They  become  covered  with  granulations,  which  serve  further 
to  protect  them,  and  thus  are  brought  about  the  conditions  known 
as  pachymeningitis  externa,  or  periphlebitis  of  the  lateral  sinus, 
as  the  case  may  be.  With  this  disease-picture  at  hand,  the  pain 
is  likely  to  be  of  a  trifling,  ill-defined,  dull  nature,  but  if  the  pus 
extends  outward  between  the  dura  and  the  bone,  or  between  the 


338  PAIN   IN   DISEASES    OF    THE    EAR 

sinus  and  the  bone,  we  have  the  picture  either  of  an  extradural 
or  of  a  perisinus  abscess.  We  speak  of  a  "closed"  extradural 
abscess  if  the  opening  through  which  the  pus  has  penetrated  to 
the  dura  is  so  small  as  to  be  nearly  undemonstrable ;  but  if,  on 
the  other  hand,  the  communication  with  the  purulent  mastoid 
cavity  is  greater,  we  speak  of  such  a  condition  as  an  "open" 
extradural  abscess.  I^aturally  the  pain  in  a  closed  extradural 
abscess  is  much  more  severe  than  in  the  open  type.  If  the  pus 
spreads  out  toward  the  tip  of  the  petrous  portion  of  the  temporal, 
then  periorbital  pains  often  arise,  which  N^eumann  holds  to  be 
characteristic  for  this  type  of  extradural  abscess.  On  the  con- 
trary, if  the  abscess  spreads  more  laterally  in  the  middle  fossa 
of  the  skull,  pain  and  swelling  in  the  temporal  region  near  the 
zygomatic  process  simultaneously  arise,  as  Ruttin  has  described. 

Perisinus  abscess  may  also  cause  very  severe  pain,  especially 
if  the  pus  collects  in  the  bony  sinus  groove  between  the  mem- 
branous and  bony  sinus  walls,  where  it  often  remains  under  such 
high  pressure  that,  upon  opening  the  mastoid  process,  it  gushes 
forth  in  a  pulsating  stream.  Still  greater  may  the  pain  become, 
if,  besides  the  pus,  gas  forms  (gas  abscess),  and  raises  the  pres- 
sure to  a  very  high  degree.  Perisinus  abscess,  like  extradural 
abscess  in  the  posterior  fossa,  causes  a  more  or  less  severe  head- 
ache in  the  occipital  region.  If  the  suppuration  destroys  the  dura 
mater,  then  intradural  suppuration,  meningitis,  temporal  lobe 
abscess,  cerebellar  abscess,  or  sinus  thrombosis  may  arise. 

Intradural  suppuration  is  such  a  rarity,  and  so  seldom  clinic- 
ally pure  in  type,  that  with  respect  to  pain  as  a  symptom  it  offers 
very  little  that  is  characteristic.  On  the  contrary,  otogenic  men- 
ingitis may  produce  a  tolerably  pronounced  picture,  since  in  it  the 
pain  is  extraordinarily  intense,  of  a  sticking  or  tearing  character, 
and  accentuated  in  its  last  phase.  I  am  accustomed  to  describe  this 
to  my  students  in  the  following  manner :  The  location  of  this  pain 
varies  according  to  the  extension  of  the  meningitis.  The  basal  type 
usually  causes  occipital  or  frontal  headache,  but  the  head  type,  that 
is,  the  form  of  suppuration  which  spreads  out  over  the  convexity  of 
the  brain,  produces  pain  at  the  vertex  of  the  skull.     Character- 


LABYRINTH  339 

istic,  also,  of  meningitis  are  the  remissions  of  pain,  great  suffering 
being  often  followed  bj  a  period  of  comparative  ease  and  comfort. 

Brain  abscesses  may  also  exist  in  the  middle  and  posterior 
fossae.  Headache  is  seldom  lacking  in  these  cases,  and  may  be 
referred,  in  both  cerebellar  and  temporal-lobe  abscesses,  to  the 
frontal  or  occipital  regions.  In  temporal-lobe  abscess  it  is  not 
seldom  localized  at  the  vertex  of  the  skull,  but  in  both  temporal- 
lobe  and  cerebellar  abscesses  the  pain  is  usually  limited  to  the 
half  side  of  the  head — hemicrania. 

Middle-ear  Catarrh. — Middle-ear  catarrh  is  a  frequent  cause 
of  pain,  especially  in  children.  This  pain,  to  be  sure,  is  not 
especially  intense,  but  may,  through  its  sticking  character,  be 
quite  disagreeable.  It  seems  that  such  pains  are  induced 
through  the  strong  retraction  of  the  membrana  tympani ;  at  least, 
this  is  true  of  those  cases  in  which  the  drum  is  markedly  re- 
tracted, for  they  vanish  after  inflation  of  the  tympanic  cavity,  or 
after  aspiration  through  the  external  auditory  canal.  High- 
grade  inveterate  catarrh,  with  maximal  retraction  of  the  drum, 
which  is  of  a  milky  color,  also  causes  pain,  which  is  not,  how- 
ever, to  be  influenced  through  Politzerization,  catheterization  or 
massage,  because  the  drum  is  fixed  in  the  retracted  position  and 
cannot  be  corrected  through  these  manipulations.  In  these  cases 
the  pain,  nevertheless,  ceases  immediately  if  one  introduces  a  hook 
■\yith  a  straight  shank  just  in  front  of  the  hammer  and  draws  the 
entire  membrane  outward,  after  the  method  which  Ruttin  has 
described. 

Otosclerosis. — In  this  disease,  which  consists  of  pathological 
changes  in  the  bony  labyrinth  capsule  and  which  has  an  exquisite 
hereditary  anamnesis,  but  whose  etiology  is  still  unknown,  pains 
are  seldom  to  be  found.  However,  there  exist,  sometimes,  in  addi- 
tion to  diminished  hearing,  noises  and  manifold  paresthesias 
localized  or  diffused  through  the  entire  ear  tract,  as  well  as  pain- 
ful sensations  in  the  external  canal,  and  in  the  surrounding  struc- 
tures. 

Labyrinth. — Whether  pains  of  distinctly  labyrinthine  origin 
are  to  be  recognized  or  not  has  hitherto  not  certainly  been  proven. 


340  PAIN   IN    DISEASES    OF    THE    EAR 

However,  pains  in  labyrinth  disease  scarcely  come  into  considera- 
tion in  relation  to  the  other  extraordinarily  troublesome  and  dis- 
tressing symptoms,  such  as  difficulty  of  hearing,  noises,  dizziness, 
vomiting,  etc. 

Referred  Pains.-^First  of  all,  there  are  pains  due  to  diseased 
teeth,  which  may  so  closely  simulate  aural  pains  that  a  typical 
disease-picture  is  described  as  otalgia  excarie  dentium,  since  a 
bad  tooth  is  so  often  the  cause  of  a  pain  described  by  the  patient 
as  localized  in  the  ear.  Secondly,  swollen  glands  in  the  neck 
region  may  produce  pains  which  the  patient  falsely  refers  to  the 
ear  on  the  side  affected.  Especially,  however,  do  inflammations 
in  or  around  the  tonsils  (peritonsillar  abscess)  produce  pains 
which  the  patient  describes  with  great  certainty  as  being  situated 
in  the  ear.  These  pains  are  increased  by  every  act  of  swallow- 
ing, because  muscles  of  the  Eustachian  tube  are  thus  brought  inte 
action. 


CHAPTEK  XVII 

PAIN    IN    DISEASES    OF    THE    NOSE  i 

The  Sensory  Nerves  of  the  Nose, — The  nose  receives  its  sensi- 
bility from  the  first  two  branches  of  the  trigeminus.  The  lateral 
wall  receiving  its  sensory  snpply  from  the  anterior  and  posterior 
ethmoidal  nerves,  which  take  their  origin  from  the  first  branch 
of  the  trigeminus,  while  the  infraorbital  and  sphenopalatine 
nerves,  which  come  from  the  second  branch,  participate  in  the 
innervation  of  the  other  parts.  The  nervi  septinarium,  which 
are  the  sensory  nerves  of  the  septum,  also  have  their  origin  in 
the  second  branch  of  the  fifth  nerve.  Of  the  sinuses  the  frontal 
sinus  and  the  anterior  ethmoidal  cells  receive  their  nerve  supply 
from  the  ophthalmic  ramus  (trigeminus  I),  while  the  posterior 
ethmoidal  cells  and  the  sphenoidal  sinus  are  supplied  by  the  nervi 
nasalis  lateralis  superiores  and  the  nervi  ethmoidales  posteriores. 

The  exact  relations,  according  to  the  description  of  Zucker- 
kandl,  are  the  following:  The  nervus  nasalis  anterior  passes 
through  the  foramen  ethmoidale  anticum  toward  the  anterior 
cavity  of  the  skull,  where  it  extends  to  the  edge  of  the  cribriform 
plate  toward  the  anterior  portion,  and  is  there  covered  by  the 
hard  sheath  of  the  dura  mater;  then,  after  passing  through  the 
ethmoidal  canal,  it  goes  to  the  nasal  cavity,  where  it  divides  into 
the  ramus  septinarium,  the  ramus  lateralis,  and  the  ramus  an- 
terior. The  posterior  nerves  of  the  nose  are  derived  from  the 
sphenopalatine  ganglion,  and  after  passing  through  the  fora- 
men enter  the  nasal  cavity,  where  they  are  distributed  to  the 
lateral  and  median  Avail.     The  nervus  nasopalatinum  scarpi,  the 

1  By  Privat  ^ocent  Dr.  Emil  Glas,  assistant  in  the  University  Clinic  ia 
Vienna  (Director  Hofrat  Chiari). 

341 


342  PAIN    IN    DISEASES    OF    THE   NOSE 

true  septum  nerve,  which  originates  from  tlie  same  source,  sup- 
plies the  anterior  mucous  membrane  of  the  pahite  after  having 
passed  through  the  canalis  incisorus. 

Diseases  Which  Produce  Pain  and  Their  Manner  of  Produc- 
tion.— Introitus  narium,  folliculitis,  eczema  introitus,  and  the  spe- 
cific inflammations  in  the  region  of  the  anterior  portions  of  the 
septum  produce  pains  such  as  one  finds  in  all  inflammations,  and 
need  no  special  explanation.  One  should  never  forget,  in  acute 
pains  arising  suddenly  in  the  region  of  the  introitus,  closely  to 
inspect  the  anterior  angle  of  the  entrance  of  the  nose,  for  in  this 
place  one  often  finds  a  hidden  folliculitis,  or  a  small  retention  of 
pus,  which  may  easily  produce  severe  pain.  This  is  of 
special  importance  in  case  of  erysipelas,  which  not  infrequently 
begins  at  the  introitus  narium.  It  is  well  to  mention  the  sej)tum 
abscesses,  which  are  always  accompanied  by  severe  pains,  and  are 
most  frequently  of  traumatic  origin.  Pains  in  the  region  of  the 
cartilaginous  portion  of  the  nasal  septum,  combined  with  a  sten- 
osis of  traumatic  origin,  at  the  nasal  entrance,  point  to  the  forma- 
tion of  a  septum  abscess.  The  pains  may  be  caused  either 
through  inflammatory  irritation  of  the  terminal  ramification  of 
the  septal  nerves,  through  compression  or  degeneration,  or  through 
pressure  from  the  supiDurating  hematoma.  Long,  persistent 
pains,  after  a  discontinuation  of  suppuration,  point  to  a  fracture 
or  to  a  spreading  of  the  fissures  of  the  skull. 

Nasal  Stenosis. — The  various  headaches  that  are  caused  by 
nasal  stenosis  deserve  special  consideration,  for  they  are  often 
accompanied  by  other  phenomena,  such  as  psychical  depression, 
inattentiveness,  loss  of  appetite,  neurasthenic  symptoms,  and  lack 
of  concentration.  These  phenomena,  wdiich  were  mentioned  by 
Piorry  as  symptoms  of  rhinostenoma,  are  caused  by  nasal  polypi, 
large  hypertrophies,  higher  grade  septum  deviations,  and  tumors 
of  the  nose,  and  can  be  cured  by  endonasal  therapy. 

Hartmann,  in  his  work  on  "Xasal  Headaches  and  Xasal  Xeu- 
rasthenia,"  has  given  the  following  explanation  for  headaches 
caused  by  nasal  stenosis:  If  too  little  oxygen  passes  into  the 
lungs  through  a  partly  stenosed  nose,  and  consequently  a  diminu- 


EMPYEMA  343 

tion  of  exhaled  air,  as  is  physiologically  necessary,  occurs,  the 
oxygen  content  of  the  blood  is  diminished  and  an  accumula- 
tion of  carbon  dioxid  takes  place  in  the  blood.  It  is  not  only  the 
accumulation  of  carbon  dioxid  that  is  to  be  considered,  but  there 
are  other  by-products  formed  that  are  classed  as  toxins.  Hart- 
mann  states  that,  through  partaking  of  poor  nutritive  matter,  a 
bad  influence  is  produced  upon  the  nervous  organism,  and  that 
only  in  this  way  is  the  appearance  of  headaches  and  neuras- 
thenic symptoms  to  be  explained.  Just  as  neurasthenic  condi- 
tions appear  in  persons  v^^ho  are  crowded  into  closed  or  poorly 
ventilated  ajDartments,  so,  also,  difiiculties  are  called  forth  through 
lack  of  nasal  breathing-space. 

In  children  with  adenoid  vegetations  Lichtwitz  and  La- 
brayes  have  proven  that  the  oxygen  of  the  blood  and  the  number 
of  red  blood-corpuscles  are  considerably  reduced,  while  the  white 
ones  are  increased ;  and  that,  upon  removal  of  the  adenoids,  the 
number  of  red  corpuscles  and  the  oxygen  constituents  of  the 
blood  are  heightened.  This  change,  especially,  should  be  consid- 
ered by  those  who  do  not  estimate  highly  enough  the  importance 
of  adenoids,  and  who  deny  the  disappearance  of  a  number  of 
reflex  symptoms  after  the  nasal  pharynx  has  been  freed  of  its 
encumbrances.  The  headaches  produced  by  nasal  stenosis  can, 
in  most  cases,  be  cured  through  operative  procedures.  However, 
one  must  not  forget  that  quite  a  number  of  internal  diseases  may 
also  produce  these  cephalalgias,  which  fact  should  receive  consider- 
ation in  applying  therapeutic  measures  (see  Headache,  Chapter 
XIV,  page  262). 

Empyema. — The  headaches  arising  in  empyemas  of  the  sinuses 
are  found  in  acute  as  well  as  in  chronic  empyemas,  and  each  has 
a  different  genesis.  Should  it  be  possible  that,  at  the  same  time 
with  the  inflammatory  changes  of  the  sinus  mucous  membrane,  the 
terminal  ramifications  of  the  sensory  nerve  apparatus  also  suffer 
inflammatory  changes ;  or  should  it  be  possible  that  distant  in- 
fluences might  also  be  acting  as  causative  factors  (the  latter  be- 
ing classified  in  the  group  of  referred  pains),  only  after  exclusion 
of  these  factors  is  it  proper  to  think  of  the  neuralgic  pains,  which, 


344  PAIN   IN    DISEASES    OF    THE   NOSE 

arising  in  cases  of  empyema,  can  be  traced  back  to  a  stasis  of 
secretion  and  secondary  pressure  phenomena.  The  other  neu- 
ralgic pains  caused  by  nasal  affections  will  be  considered  in  regular 
order. 

In  his  work  on  ''The  Significance  of  Rhinology  for  Internal 
Diagnosis  and  Therapy"  Glas  has  especially  called  attention 
to  and  emphasized  the  fact  that  often  the  cause  of  these  headaches 
is  not  discovered  for  a  long  time,  and  that  all  possible  measures 
to  relieve  the  sufferings  may  be  utilized  without  result. 

Other  pains  found  in  inflammatory  states  of  the  sinus  are  the 
local  paijis  that  occur  in  the  cavities  themselves,  as  aching,  boring 
and  piercing  pains,  and  occasionally,  as  in  cases  of  stasis, 
severe  and  throbbing  pains.  These  pains,  which  are  similar  to 
sinus  abscess  pains,  may  also  be  produced  by  percussion  of  the 
external  wall  of  the  suspected  sinus,  or,  if  previously  existing, 
may  be  increased.  In  this  way  in  those  sinuses  whose  walls  are 
percussible  (as  the  maxillary  sinus,  frontal  sinus  and  anterior 
ethmoidal  cells)  one  is  able  to  decide,  in  some  cases,  even  the 
extent  of  the  diseased  area,  and  the  size  of  the  diseased  sinus. 
Occasionally,  through  the  detection  of  percussion  pains,  one 
can  determine  whether  there  are  abscess  formations  and  septum 
deviations  in  the  frontal  sinus.  These  observations  may  be  sub- 
stantiated by  X-ray  examinations. 

Finally,  pains  arising  in  otlicr  parts  of  the  hody  may  bs 
genetically  related  to  diseases  of  the  nose,  especially  to  empyema, 
as  described  by  Flies  in  several  cases.  These  phenomena  belong 
to  the  large  group  of  reflex  neuroses  of  the  nose.  A  careful  study 
of  these  pain  reflexes  has  also  been  made  by  Head,  who  finds 
that  diseases  of  the  olfactory  (upper  part  of  the  nose)  cause  re- 
ferred pain  and  superficial  tenderness  over  the  nasal  and  mid- 
orbital  areas  (q.  v.)  :  disease  of  the  nasopharyngeal  part  of 
the  respiratory  tract  may  cause  pain  and  tenderness  in  the 
nasolabial  area.  But,  as  a  rule,  the  nasal  affections  do  not 
cause  pain.  Since  the  i^ressure  pains  are  of  value  for  the 
localization  of  the  diseased  areas,  the  statement  of  the  patient 
in  regard  to  the  location  of  the  headache  would  be  of  special  diag- 


DISEASE    OF  THE    SPHENOPALATINE    GANGLION       345 

nostic  importance,  were  it  not  for  the  fact  that  there  are  many 
cases  in  which  the  subjective  sensations  do  not  coincide  with  the 
objective  findings.  Similarly,  one  often  finds  that  patients  with 
a  disease  of  the  sphenoid  sinus  or  posterior  ethmoidal  cells  often 
refer  the  pains  to  the  region  of  the  anterior  sinuses,  wdiich,  upon 
examination,  are  found  perfectly  healthy,  and  vice  versa ;  so 
that  one  cannot  use  pain  localization  as  an  absolute  indicator  in 
the  topical  diagnosis  of  diseased  sinuses. 

That  neuralgias  may  be  produced  by  suppuration  of  the  sinuses 
has  been  proven  by  Peyre,  who  had  a  case  of  facial  neuralgia, 
which  had  been  complicated  by  the  removal  of  the  Gasserian  gan- 
glion, and  which  disappeared  after  a  septum  and  maxillary  sinus 
operation ;  or  by  Hartmann,  who  had  a  case  of  trigeminus  neu- 
ralgia, accompanied  by  insomnia  of  several  weeks'  duration,  which 
was  completely  cured  after  removing  a  caseous  mass  from  the 
antrum.  The  writer  is  at  present  observing  a  case  of  intensive 
infraorbital  neuralgia  of  several  weeks'  duration,  which  was 
treated  galvanically  without  result,  and  which  completely  disap- 
peared after  Cowper's  alveolar  operation  of  the  maxillary  sinus. 
Also,  cases  of  frontal  sinus  empyema,  accompanied  by  supraorbital 
neuralgias,  are  not  infrequently  cured  by  operation. 

Headache  from  Disease  of  the  Sphenopalatine  Ganglion. — The 
experiments  of  Greenfield  Seiider,  who  believes  that  the  spheno- 
palatine ganglion  is  an  important  factor  in  the  production  of  head- 
aches of  nasal  origin,  are  of  much  interest.  He  believes  that,  sec- 
ondarily, the  ganglion  is  sympathetically  affected  in  intranasal  in- 
flammation, and  applies  his  therapeutic  measures  accordingly.  He 
has  tried  to  anesthetize  the  ganglion  by  making  cocain  applica- 
tion behind  the  posterior  end  of  the  middle  turbinate,  and  suc- 
ceeded in  several  of  his  cases.  At  the  same  time  he  describes 
cases  in  which  headaches  have  disappeared  after  cauterization  of 
these  areas,  a  fact  which  seems  to  point  to  an  affection  of  the 
ganglion. 

Obstructed  Sinuses. — Here  we  may  consider  the  observations 
which  convince  the  writer,  as  well  as  Hartmann,  that  also  in  cases 
of  nondiseased,  but  obstructed,  sinuses,  or  in  cases  of  poor  com- 


346  PAIN   IN   DISEASES    OF    THE   NOSE 

munication  between  the  sinuses  and  the  nose,  severe  pains  may 
exist,  which,  upon  removal  of  the  obstructions,  are  immediately 
decreased.  I  know  of  a  colleague  whose  left  maxillary  sinus 
I  must  puncture  four  or  five  times  a  year,  without  being  able 
to  detect  at  any  time  any  inflammatory  affection  of  the  antrum. 
However,  I  noticed  at  the  first  puncture  that  I  made,  on  account 
of  the  severe,  one-sided  headache,  that  by  the  inflation  of  the 
antrum  with  air  the  characteristic  antrum  murmur  was  missing, 
and  that  it  took  more  pressure  than  normal  to  inflate ;  therefore,  I 
was  forced  to  conclude  that  the  ostium  relations  were  unsatisfac- 
tory, and  were  either  injured  or  had  been  insufficiently  developed. 
Although  there  was  no  secretion  to  be  found  in  the  return  solution 
after  douching  the  antrum,  nevertheless  the  colleague  felt  well 
after  the  rinsing.  The  headaches  disappeared  for  some  time,  until 
the  conditions  demanded  another  puncture,  which  had  to  be  re- 
peated four  or  five  times  a  year.  The  patient  has  not  accepted 
my  proposition  to  enlarge  the  communication  and  thus  relieve  him 
of  his  sufferings,  although  this  operation  might  free  him  of  his 
pains  forever.  Such  cases  indicate  that  the  destruction  of  the 
communication,  or  a  hindrance  between  the  sinuses  and  the  nose, 
can  produce  headaches  even  where  there  is  no  sinusitis  present. 

Hartmann  has  also  made  similar  observations,  and  gives  the 
following  explanation  to  prove  the  truth  of  his  assertion:  (1) 
In  those  cases  in  which  existing  frontal  headaches  cause  one  to 
believe  that  there  is  a  frontal  sinus  disease,  the  frontal  sinus  may 
be  opened  without  finding  any  diseased  condition.  In  such 
cases  the  pains  may  disappear  after  opening  the  frontal  sinus,  to 
reappear,  however,  when  the  external  opening  heals,  unless  in  the 
meantime  a  communication  has  been  made  with  the  nose.  If  a 
communication  has  been  made,  the  pains  are  absent  as  long  as  the 
communication  exists. 

(2)  There  are  cases  in  which,  after  an  operation  on  the 
frontal  sinus,  exacerbatory  symptoms  arise  in  the  form  of  head- 
aches without  a  real  recrudescence  of  the  disease,  but  only  a  clo- 
sure of  the  opening  into  the  nose,  and  it  is  this  closure  which  pro- 
duced the  frontal  headaches.     In  such  case  it  suffices  to  open  the 


TUMORS  347 

thin  scar  on  the  forehead  with  a  sound.  This  allows  the  entrance 
of  air,  and  thus  relieves  the  headaches. 

(3)  The  third  deduction  of  Hartmann's  is  not  absolutely 
unchallengeable,  for  in  those  cases  in  which  an  empyema  had  ex- 
isted (about  eight),  and  which  were  cured,  the  reason  that  the 
headaches  disappeared  after  the  formation  of  a  communication 
between  the  nose  and  the  frontal  sinus  can  be  traced,  possibly,  to 
a  retention  of  secretion,  and  not  to  the  exclusion  of  air  in  the  sinus. 

Tumors. — Headaches  are,  furthermore,  a  very  important 
symptom,  and  are  often  the  most  prominent  phenomena  observed 
in  the  malignant  tumors  of  the  nose.  Harmen  and  Glas  have 
shown  that  the  headache  was  the  most  important  symptom  in  nine 
out  of  thirty-two  cases  observed.^  These  headaches,  in  spite  of 
the  better  drainage  of  the  pus,  the  result  of  an  existing  empyema, 
continued  in  the  same  degree  after  the  removal  of  the  growth.  This 
showed  that  a  deeper  affection  must  have  been  the  cause.  The  two 
following  cases  may  prove  the  truth  of  this  assertion:  (1)  Pa- 
tient Z  came,  for  dispensary  treatment,  with  severe  pains  of  the 
right  cheek,  accompanied  by  periodic,  right-sided  headaches. 
Rhinoscopical  examination  showed  pus  in  the  right  nostril,  espe- 
cially in  the  middle  meatus.  Considerable  pain  was  present  upon 
pressure  on  the  right  maxillary  sinus  wall.  The  probable  diag- 
nosis made  at  the  time  was  empyema  of  the  antrum.  Puncture 
of  the  right  maxillary  sinus  was  positive.  Since  the  suppuration 
was  not  lessened  by  repeated  douching  through  the  ostium,  the 
maxillary  sinus  was  opened,  through  the  alveolar  process.  Re- 
peated douching  was  given.  ISTevertheless,  the  pain  did  not  cease. 
The  continuation  of  the  pains,  in  spite  of  the  opening  and  the 
douching  of  the  antrum,  indicated  that  another  process  must  be 
present  besides  that  of  empyema.  The  histological  examination 
of  the  resected  lower  turbinate  showed  cylindrical-celled  carci- 
noma. 

(2)  A  woman,  fifty  years  of  age,  had  a  polypus  removed 
from  the  right  nostril  a  year  previous  to  her  admittance.  Eight 
months  later,  on  account  of  profuse  suppuration,  the  maxillary 

1  Deutaclle  Festschrift  fiir  Chirurgie. 


348  PAIN    m    DISEASES    OF    THE   NOSE 

sinus  was  opened  through  the  alveolus.  In  this  case  there  were 
two  factors  which  indicated  the  probability  of  a  malignant  for- 
mation of  new  tissue,  namely,  the  intense  pain  and  the  fetid  con- 
dition of  the  returning  fluid  of  the  douching  solution.  The  his- 
tological examination  of  an  excised  mass  then  gave  the  diagnosis 
of  stratified  epithelioma. 

The  cause  of  the  headaches  in  maligiiant  tumors  of  the  nose 
may  be  various.  The  origin  may  be  one  of  the  following:  (1) 
reflex  irritability,  (2)  blood  and  lymph  stasis,  (3)  nerve  pressure, 
(4)  meningeal  irritation,  (5)  the  result  of  an  empyema  occurring 
at  the  same  time. 

Zuckerkandl  shows,  in  his  anatomy  of  the  nose,  the  superficial 
position  of  the  ethmoidal  nerve  in  the  anterior  portion  of  the 
skull,  and  adds  that  this  exposed  position  allows  approximating 
swellings  to  cause  pressure  symptoms.  That  headaches  some- 
times arise  as  localized  symptoms  is  sho^^^l  in  the  second  case, 
cited  by  Harmen  and  Glas  in  their  article  on  "Malignant  Tu- 
mors," in  which  right-sided,  frontal  headaches  existed.  Autopsy 
showed  penetration  of  the  roof  of  the  orbit  and  a  growth  of  the 
tumor  into  the  right  frontal  sinus.  We  deduce,  therefore,  that, 
after  cleansing  of  the  sinuses,  constant  pains  should  call  forth 
the  suspicion  of  malignant  neoplasms.  In  one  of  my  last  cases, 
on  autopsy,  I  found  a  meningeal  hyperemia,  which  may  have  been 
the  cause  of  the  violent  and  increasing  cephalalgia  during  the 
last  days  of  the  patient's  life. 

Finally,  we  cannot  deny  that  those  swollen  areas  in  the  interior 
of  the  mucous  membrane,  found  on  section,  may,  by  compressing 
certain  structures, ^ very  frequently  be  the  cause  of  severe,  continu- 
ous headaches. 

DIAGNOSIS 

In  cases  of  acute  empyema  the  pains  are  sometimes  very  vio- 
lent, and  one  cannot  be  reminded  too  often  of  the  fact  that,  when 
pains  arise  during  a  coryza,  or  an  influenza,  a  thorough  rhino- 
logical  examination  should  be  made.  The  result  of  therapeutic 
measures  in  empyema  is  often  marvelous.     A  puncture  through 


DIAGNOSIS     •  349 

the  inferior  meatus,  or  a  douching  through  the  natural  opening 
in  sinusitis  maxillaris,  or  the  application  of  cocain  on  the 
anterior  end  of  the  middle  turbinate,  in  frontal-sinus  affections, 
can  relieve  the  most  acute  pain.  Unfortunately,  even  at  the  pres- 
ent time,  one  finds  many  cases  which  are  treated  for  weeks,  either 
galvanically,  or  faradically,  are  massaged,  or  receive  other  result- 
less  treatment,  without  the  attending  physicians  even  surmising 
that  the  sinus  is  diseased. 

A  test  of  importance,  which  I  have  introduced  into  rhinology, 
may  frequently  be  applied.  The  principle  of  this  test  is  the  fol- 
lowing: The  tuning  fork,  which  is  held  anteriorly  in  the  median 
line  above  the  bridge  of  the  nose,  is  lateralized  to  the  side  where 
the  diseased  sinus  exists.  In  case  the  ear  is  not  affected  the 
patient  hears  the  tuning  fork  only  on  the  side,  or  more  intensely 
on  the  side  in  which  the  sinus  is  affected. 

This  method,  which  was  tested  in  several  hundred  cases, 
affords  important  service  to  one  who  is  not  thoroughly  conversant 
with  exact  rhinological  technic,  as  he  is  able  to  state,  in  cases  of 
neuralgic  headaches,  whether  they  can  be  traced  back  to  affections 
of  the  sinuses.  I  have  seen  cases  in  which  patients  complaining 
of  severe  neuralgias  were  sent  to  a  rhinological  specialist  for 
examination,  in  whom  Glas's  tuning-fork  test  proved  to  be  nega- 
tive (i.  e.,  the  tuning-fork  was  heard  only  at  the  point  of  appli- 
cation, or,  as  the  patients  said,  heard  alike  at  all  parts  of  the 
head),  and  in  whom,  as  a  result  of  complete  rhinological  examina- 
tion, empyema  could  be  excluded  as  the  cause  of  the  neuralgic 
pains.  On  the  other  hand,  this  test  affords  the  rhinologist  im- 
portant service  in  a  diagnostic  and  prognostic  manner,  in  regard 
to  which  Glas  gave  more  explanatory  details  at  the  International 
Rhino-Laryngological  Convention  in  Berlin,  1911.  * 

At  the  same  time  one  must  not  forget  those  cases  in  which 
there  is  no  stenosis,  but  in  which  hypertrophy  of  the  middle  tur- 
binate is  the  determining  factor  of  the  headaches,  which  disappear 
after  resection  of  this  part.  These  headaches  are  classed  by 
some  as  symptoms  of  stenosis,  but  by  others  they  are  placed  in 
the  groufi  of  Flies'  reflex  symptoms.     At  any  rate  the  pressure  of 


350  PAIN    IN    DISEASES    OF    THE    NOSE 

the  turbinates  on  the  septi  may  cause  reflex  pains.  The  explana- 
tion of  Casali,  however,  is  more  reasonable.  He  assumes  the 
cause  to  be  compression  of  the  vessels  of  the  nasal  mucous  mem- 
brane, which  are  in  communication  with  the  veins  of  the  dura 
mater  and  the  superior  longitudinal  sinus,  the  blood  and  lymph 
stasis  of  the  mucous  membrane  of  the  nose  causing  a  stasis  in  the 
dura  covering  the  brain.  There  is  no  doubt  that,  in  such  cases, 
the  result  of  resection  of  the  hypertrophy  of  the  turbinate  is  strik- 
ing. On  negative  internal  findings,  the  diagnostic  sig-nificance  of 
this  therapy  should  not  be  forgotten.  Here  may  be  included  those 
cases  in  which  severe  neuralgias  are  relieved  by  endonasal  opera- 
tions. In  regard  to  this  point,  I  have  expressed  myself  in  my 
work  on  "The  Significance  of  Rhinology  for  Internal  Diagnosis 
and  Therapy,"  in  the  following  manner :  Any  one  who  has  had 
occasion  to  cure  a  severe  neuralgia  by  an  endonasal  operation  will 
know  how  to  emphasize  the  importance,  indeed  the  utmost  neces- 
sity, of  a  rhinological  examination  in  every  case  of  neuralgia  of 
the  fifth  nerve.  The  following  cases  may  illustrate  the  foregoing 
statement : 

(1)  In  the  case  of  a  patient  who  had  suffered  for  years  with 
a  neuralgia  of  the  infraorbital  nerve,  I  found,  by  rhinological 
examination,  a  rhinolith  lying  under  the  middle  turbinate  and 
pressing  upon  the  processus  uncinatus.  On  its  removal  the  neu- 
ralgia disappeared. 

(2)  A  patient  who  had  tried  various  therapeutic  treatments 
for  a  trigeminal  neuralgia,  in  his  despair  consulted  a  rhinologist. 
By  chiseling  a  broad  crista  of  the  septum,  which  extended  in  an 
especially  sharp  angle  to  the  middle  turbinate,  relief  of  the  neu- 
ralgia was  at  once  obtained.  A  single  example  of  this  kind  is  of 
more  value  than  a  multitude  of  reflections,  and  proves  the  utmost 
necessity  of  a  rhinological  examination  of  such  cases. 

In  conclusion,  it  may  be  added  that  sometimes,  after  a  radi- 
cal operation  on  the  frontal  sinus,  neuralgias  of  the  supraorbital 
nerve  arise.  Therefore,  it  seems  rational  that,  while  doing  the 
Killian  operation,  one  should  remember  this  fact,  and  resect  the 
supraorbital  nerve 


CHAPTER  XVIII 

PAIN   IN  DISEASES   OF  THE   THEOAT 

PAIN    IN    DISEASES    OF    THE    PHARYNX  ^ 

The  sensory  nerve  of  the  pharynx  is  the  lingual.  From  it  are 
derived  the  sensory  receptors  of  the  anterior  palatine  arch,  the 
tonsils,  the  floor  of  the  mouth,  and  the  tongue.  This  and  the 
glosso-pharyngeal  divide  the  supply  of  these  parts,  while  the  re- 
gion of  the  gingiva  is  supplied  by  the  alveolaris  inferior. 

Pain  in  Acute  Diseases. — All  the  inflammatory  processes  in  the 
region  of  the  pharynx  contribute  toward  pain  production,  for  in- 
stance, the  different  forms  of  angina,  the  inflammation  of  the 
pharyngeal  tonsil,  retropharyngeal  abscess,  and  herpes,  febrile  and 
zoster  form.  In  this  group  of  diseases  phlegmonous  angina,  retro- 
pharyngeal abscess,  and  diphtheritic  inflammation  are  especially 
prominent. 

Phlegmonous  angina  often  produces  very  severe  pain,  which 
is  increased  by  every  movement  of  the  mouth,  and  which  has  radia- 
tions in  the  ear  which  are  often  unbearable.  These  are  sometimes 
produced  through  a  pus  area  developing  in  the  deeper  tissues, 
sometimes  through  an  inflammatory  edema  of  the  surroundings. 
The  pains  are  sometimes  boring,  sticking,  excessive,  or  trivial. 
The  localization  of  the  pain  is  frequently  inexact.  When  it  is 
located  in  the  nasopharynx,  in  the  ear,  or  in  the  region  of  the 
ostium  tubse,  the  increased  pain  upon  pressure  outside  on  the 
anterior  mandibular  muscles  is  characteristic. 

Upon  opening  a  "peritonsillar  abscess,  the  making  of  the  inci- 
sion in  the  right  place,  that  is,  at  the  point  where  the  pus  conies 

'  By  Privat  Doeent  Dr.  Emil  Glas,  of  Vienna  University. 

351 


352  PAIN    IN    DISEASES    OF    THE    THROAT 

nearest  to  tlie  surface,  is  of  the  utmost  importance,  since  the  inci- 
sion and  dilatation  of  the  point  of  incision  in  an  edematous 
but  not  pus  infiltrated  area  occasion  very  severe  pains,  which  fre- 
quently cause  fainting.  On  the  contrary,  the  incision  in  the  in- 
filtrated area  is  relatively  painless,  and  causes  an  instantaneous 
improvement. 

Retropharyngeal  abscess  often  produces  pain  similar  to  that 
of  phlegmonous  angina,  save  that  in  the  former  the  location  cor- 
responds to  the  deeper  seat  of  the  affection,  which  lies  further 
back  and  lower  down.  Deglutition  also  occasionally  is  difiicult 
and  is  associated  with  severe  pain,  which  is  increased  by  the  swell- 
ing of  the  corresponding  glands  of  the  neck.  The  acute  process, 
as  a  rule,  does  not  affect  the  vertebra,  but  chronic  retropharyngeal 
abscess  may  cause  necrotic  processes  in  the  vertebral  column.  Con- 
cussion of  the  vertebral  column,  produced  from  above,  causes  no 
increase  of  the  pain  in  the  acute  form. 

In  diphtheria  swallowing  pains  are  usually  severe.  Fre- 
quently, from  the  swelling  of  the  velum,  the  taking  of  food  be- 
comes difficult  and  painful,  although  in  many  cases  no  trouble  of 
any  sort  is  present.  Generally  there  occurs  a  painful  swelling  of 
the  submaxillary  glands;  likewise,  of  the  lymph  glands  lying 
under  the  sternomastoid  muscle;  these  frequently  grow  into  a 
large,  very  painful  lump,  especially  sensitive  to  the  touch.  Here, 
one  must  not  forget,  in  pharyngeal  diphtheria,  the  pains  arising 
(through  the  general  infection)  in  the  head,  neck,  back  and  the 
region  of  the  buttocks,  which  often  cause  the  patient  very  much 
trouble. 

The  acute  infectious  diseases,  especially  influenza,  wliich 
causes  very  severe  neck  pain,  with  but  little  objective  findings, 
are  of  interest.  Escat  has  described  such  cases  and  has  diagnosed 
them  as  pharyngodynia  from  influenza.  Here  one  finds,  at  the 
most,  a  slight  degi'ee  of  erythema.  This  painful  angina  is  closely 
related  to  the  herpetic  angina  and  disappears  in-  the  course  of  a 
few  days. 

The  febrile  herpes  of  the  pharynx,  which  is  often  associated 
with  laryngeal  herpes,  appears  very  frequently  in  groups,  occur- 


PAIN   IN   DISEASES    OF    THE   PHARYNX  353 

ring,  also,  in  the  form  of  small,  diffuse,  epidermic  vesicles,  and 
is  especially  characterized  by  pain  on  swallowing.  In  a  work 
given  out  from  the  Chiari  Clinic  of  the  Vienna  University,  Glas 
mentioned  that  frequently,  after  a  short  prodromal  stage,  severe 
difficulties  of  swallowing  and  sticking  pains  occurred  in  the  throat, 
accompanied  frequently  by  hoarseness  and  difficulties  of  breath- 
ing. The  dysphagia  often  reaches  such  a  pronounced  cfegree  that 
the  patient  is  unable  to  take  nourishment.  Examination  of 
the  mesopharynx  very  frequently  gives  an  entirely  normal  pic- 
ture. Laryngoscopic  examination  first  shows  on  the  base  of  the 
tongue,  in  the  region  of  the  follicular  papillae,  on  the  vault  of  the 
pharynx  or  on  the  pharyngeal  wall,  symmetrical  vesicles.  These 
are  very  prominent,  varying  in  size  from  a  poppy  seed  to  a 
lentil,  and  are  filled  with  white  contents,  lying  on  a  red  base. 
These  vesicles  may  be  scattered,  without  any  arrangement,  or  they 
may  be  gathered  into  groups.  At  this  point  it  is  time  to  emphasize 
(as  we  shall  do  later,  in  our  description  of  chronic  affections)  the 
fact  that  one  should  always,  in  cases  of  pain  on  swallowing,  ex- 
amine the  region  of  the  hypopharynx,  w'here  these  efflorescences 
are  likely  to  occur. 

As  an  example  of  these  interesting  infections,  in  wliich  severe 
pain  is  always  present,  the  following  case  is  of  note : 

''The  patient,  fifty  years  of  age,  felt,  for  a  few  days,  weak 
and  tired ;  three  days  previous,  chills  and  high-grade  dysphagia. 
The  patient  gave  the  impression  of  being  very  ill,  the  head  being 
held  as  it  is  in  peritonitis  gravis.  The  temperature  Avas  38.9°  C. 
(102.2°  F.)  and  the  pulse  frequency  was  110.  The  pharynx  was 
perfectly  free,  and  the  tonsils  were  not  in  the  least  inflamed. 
The  opening  of  the  larynx  (aditus)  was  greatly  changed;  the 
epiglottis,  the  aryepiglottic  folds,  the  valliculai  in  the  recessus 
pyriformis,  were  covered  with  vesicles  of  a  somewhat  similar  size, 
not  very  prominent,   and  filled  with  gold-colored  contents." 

Herpes  zoster  may,  as  I  have  frequently  seen,  give  rise  to 
very  special  pain  in  the  region  of  the  pharynx,  which  assumes  a 
neuralgic  character  and  reaches  such  an  intensity  that  the  other- 
wise fairly  resistant  patient  whines  and  complains.     Kaposi  has 


354  PAIN    IN   DISEASES    OF    THE   THROAT 

described  cases  which  correspond  with  the  distribution  of  the 
maxillary  nerve,  the  pains  at  the  same  time  occurring  in  the 
cheeks,  the  palate  and  the  pharyngeal  mucous  membrane  of  the 
affected  area.  The  herpes  arises  sometimes  as  a  diffuse,  painful 
redness,  sometimes  as  a  gToup  of  efflorescences  of  a  short  duration, 
or  even  as  gangrene  of  the  rami  palatini  and  pharyngei. 
Frequently  with  the  significant  difficulties  of  swallowing  severe 
toothache  is  present,  with  the  resulting  continuous  neuralgi- 
form pains.  I  have  seen  two  cases  of  herpes  zoster  associated 
with  high-grade  dysphagia.  In  these  cases  only  the  mucous 
membrane  of  the  mouth  and  pharynx  was  affected,  and  the  efflor- 
escence was  interrupted  sharply  in  the  median  line.  Cases 
have  also  been  described  in  which  it  is  almost  impossible  either 
to  speak  or  to  chew,  each  movement  calling  forth  a  tic  dou- 
loureux. 

Herpes  zoster  is  occasionally  mistaken  for  acute  pharyngeal 
ajfections.  Here,  also,  phlegmonous  inflammation  of  the  base  of 
the  tongue  is  to  be  considered,  for  it  very  often  occasions  unbear- 
able j)ain,  and,  like  peritonsillitis,  makes  deglutition  impossible. 
The  pains,  which  are  severe,  sometimes  radiate  to  the  ear.  These 
diseases,  because  of  the  action  of  the  inflammatory  exudate  on  the 
glosso-pharyngeus,  give  rise  to  stimuli  which  are  conducted  back 
through  the  vagi,  and  are  often  associated  with  profuse  salivation, 
high-gi-ade  prostration,  and  difficulty  of  breathing. 

Pain  in  Chronic  Diseases. — Among  chronic  diseases  of  the 
pharynx,  which  cause  interesting  pains,  tuberculosis,  lues,  and 
malignant  neoplasms  of  this  region  are  prominent. 

Tuberculous  ulcers  of  the  pharynx  produce  severe  pain,  which 
is  increased  in  swallowing.  The  pain  frequently  radiates  to  the 
ear,  and  the  deeper  the  process  extends  the  more  severe  it  be- 
comes. The  maximum  is  reached  in  tuberculous  affections  of 
the  aditus  laryngis,  a  very  frequent  disease.  The  ulcers  located 
in  the  epipharynx,  especially  those  having  their  location  near  the 
tuba  of  the  ostium  of  the  pharynx,  are  very  painful,  and,  because 
of  their  location,  are  noteworthy,  since  for  their  diagnosis  an 
exact  posterior  rhinoscopy    is    necessary    (the    unskilled    rhinos- 


PAIN   m   DISEASES    OF    THE   PHARYNX  355 

copist,  in  order  not  to  overlook  these  diseased  parts,  should  use 
a  pharyngoscope). 

Swallowing,  in  cases  of  pharyngeal  tuberculosis,  is  often  very 
painful,  and  causes  vomiting,  which,  in  turn,  aggravates  the  pain. 
Very  frequently  otherwise  active  anodynes,  such  as  cocain,  mor- 
phin,  orthoform,  etc.,  are  entirely  without  effect,  and  the  physi- 
cian finds  it  necessary  to  resort  to  morphin  injections.  For  the 
severest  laryngeal  pain  the  alcohol  anesthesia  of  the  nerves  is 
especially  to  be  recommended. 

Luetic  ulcers,  at  first,  are  not  associated  with  very  great  pain, 
the  superficial  mucous  membrane  plaques  causing  only  slight 
trouble ;  and  attention  should  be  called  to  the  disparity  between 
the  extensive  process  and  the  slight  trouble  as  characteristic  of 
the  first  stage  of  syphilis.  The  first  pain  occurs  on  the  deep  exten- 
sion of  the  process,  and  may  (for  example,  in  deep,  ulcerating 
gummata)  reach  a  very  high  degree.  Gummata  of  the  base  of  the 
tongue  and  of  the  epipharynx,  lying  principally  on  the  roof  of  the 
pharynx,  may  exist,  in  which  the  most  prominent  symptom  is  the 
excessive  pain.  Diffuse  pain,  radiating  chiefly  into  the  ear, 
accompanies  this  stage  of  the  syphilitic  process.  It  is  also  to  be 
emphasized  here  that,  with  this  group  of  symptoms,  an  exact 
retronasal  examination  should  be  made,  and  the  region  of  the  cir- 
cumvallate  papillae  carefully  examined,  because  it  is  exactly  here 
that  the  concealed  seat  of  the  affection  is  often  to  be  found. 

In  carcinoma  of  the  base  of  the  tongue  there  may  be  no  pain  in 
the  early  stages.  The  patient  experiences  only  a  scratching  or  a 
tickling  in  the  neck.  Often,  upon  pronounced  movement  of  the 
tongue,  he  has  the  sensation  as  of  a  foreign  body  in  the  pharynx, 
and  his  complaint  of  this  may  lead  to  a  false  diagnosis.  The  deep 
extension  of  the  carcinoma  first  produces  severe,  often  signifi- 
cant pains  radiating  into  the  ear,  the  jaw,  or  the  larynx.  Pro- 
fessor von  Bergman  held  the  hemorrhage  and  pain  which  are  pro- 
duced through  the  movement  of  the  tongue,  and  through  the  con- 
tact of  the  hard  food,  as  characteristic  features  of  carcinoma  of 
the  tongue.  He  says :  "They  frequently  are  as  pronounced  as  in 
the  flat,  tuberculous  ulcers  on  the  margin  of  the  tongue.     Fre- 


356  PAIN    IN    DISEASES    OF    THE    THROAT 

quently  tbcj  are  neuralgic  in  character,  and  radiate  toward  the 
ear,  and  the  unhappy  patients  often  complain  fearfully"  ("Hand- 
book of  Surgery"), 

Of  the  group  of  chronic  infections  with  w4iich  severe  pain  is 
associated  i)empliic)i  of  the  mucosa  are  conspicuous.  Often  they 
suddenly  burst  open,  or  the  vanishing  vesicle,  through  hemorrhage 
of  the  submucosa,  may  occasion  an  increase  of  the  pain,  especially 
in  the  efflorescence  of  the  mucous  membrane  lying  adjacent  to  the 
pemphigus  follicle,  which  causes  a  diffuse  epithelial  desquama- 
tion, produces  a  high  degi'ee  of  dysphagia,  and,  as  a  result  of 
inanition,  quickly  incapacitates  the  patient. 

The  NEURALGIAS  OF  THE  PHARYNX,  which,  without  demonstrable 
organic  changes,  are  found  in  hysterical  individuals,  are  also  to 
be  considered.  The  patient  often,  for  hours,  will  complain  of 
lightning  pains  arising  in  the  different  parts  of  the  mouth  and 
radiating  into  the  pharynx.  Here,  one  should  always  seek  for  the 
pressure  points,  w^hich  are  located  in  the  region  of  the  laryngeus 
superior  glosso-pharjoigeus  or  the  lingualis.  Those  affections 
arising  through  tonic  contraction  of  the  swallowing  muscles  may 
be  designated  as  hysterical  dysphagia.  In  these  strong  pressure, 
accompanied  by  the  closing  of  the  teeth,  produces  a  sticking  or 
tearing  pain. 

PAIN    IN   THE    LARYNX 

■  The  sensory  component  of  the  vagus  is  the  superior  laryngeal 
nerve,  which,  arising  from  the  vagus,  runs  median  to  the  internal 
carotid  as  far  as  the  thyrohyoid  ligament.  At  the  upper  half  of 
the  greater  cornu  of  the  hyoid  bone  the  nerve  divides  into  an 
outer  and  an  inner  branch,  of  which  the  outer  has  motor  and  the 
inner  sensory  fibers.  The  latter  passes  through  the  thyrohyoid 
ligament  and  reaches  the  recessus  pyriformis,  where  it  supplies  the 
mucous  membrane  covering  the  plica  of  the  laryngeal  nerve,  and 
ends  in  the  mucous  membrane  of  the  larynx.  At  the  same  time  it 
forms  an  anastomosis  with  the  laryngeus  inferior,  and  concerns 
itself  with  the  delivery  of  sensory  nerve  fibers  to  the  recurrens. 
At  this  point,  the  observation  made  by  Massei,  of  anesthesia  of 


PAIN   IN    THE   LARYNX  357 

the  laryngeal  entrance  in  recurrens  paralysis,  may  be  cited. 
This  he  gives  as  a  reason  for  his  opinion  that  the  recurrens  really 
conducts  sensory  fibers.  My  examinations,  following  those  of 
Massei,  do  not  confirm  his  observation,  so  that  I,  as  the  result  of 
an  enormous  amount  of  clinical  experience,  and  because  of  other 
reasons,  have  reached  the  conclusion  that  the  recurrens  has  nothing 
whatever  to  do  with  the  sensibility  of  the  larynx. 

Referred  Pain. — Diseases  of  the  larynx  generally  produce  no 
referred  pain  nor  tenderness,  but  when  pain  does  exist,  it  is  gener- 
ally felt  in  either  the  superior  or  inferior  laryngeal  area,  the 
upper  area  being  particularly  associated  with  disease  of  the  epi- 
glottis and  aryteno-epiglottidean  folds,  the  lower  area  being  par- 
ticularly associated  with  disease  of  the  cords  (Head). 

Pain  in  Acute  Affections. — Laryngeal  pain  may  be  found  in 
all  acute  inflammations,  chiefly  in  those  associated  with  pus  for- 
mation. Here  the  intensity  of  the  pain  depends  especially  upon 
the  location  of  the  process.  The  aditus  laryngis,  that  is,  the 
epiglottis,  aryepiglottidean  folds  in  the  arytone,  is  the  region  in 
which  inflammation  produces  the  most  severe  pain.  It  depends, 
on  the  one  hand,  upon  the  richness  of  the  sensory  nerves  in  this 
region,  and,  on  the  other  hand,  upon  its  relation  to  the  process 
of  swallowing.  The  bolus,  gliding  over  the  aditus,  irritates  the 
inflamed  area  and  produces,  at  the  same  time,  an  increased  reac- 
tion as  well  as  pressure  pain.  A  clear  proof  of  the  increased  pain 
sensibility  in  involvement  of  the  aditus  is  found  in  acute  affec- 
tions; for  example,  in  herpes  laryngis,  involvements  of  the  ary- 
epiglottidean folds  and  the  recurrens  pyriformis  are  so  painful 
that  swallowing  becomes  impossible.  Here  the  pain  frequently 
radiates  into  the  region  of  the  base  of  the  tongue  and  the  middle 
auricular  nerve  of  the  vagus  in  the  ear  zone.  On  the  side  of  the 
larynx  a  clearly  defined  ulcer  may  frequently  be  present  for  a  long 
time  without  causing  severe  pain,  because  swallowing  is  not  dis- 
turbed. Here,  upon  manifestations  of  pain  in  these  parts,  I  again, 
suggest  a  minute  examination  of  the  entrance  of  the  larynx,  espe- 
cially of  the  recessus  pyriformis,  in  order  to  avoid  the  overlooking 
of  a  diseased  process. 


358  PAIN    IN    DISEASES    OF    THE    THROAT 

Chronic  Processes.- — Under  the  chronic  processes  are,  again, 
the  tuberculous  ulcers,  as  well  as  the  crumbling  carcinoma  (extra- 
larjngeal),  which  may  give  rise  to  an  intense,  often  unbearable, 
pain.  The  dysphagia  of  a  patient  suffering  from  a  diffuse  laryn- 
geal tuberculosis  often  reaches  such  a  high  degTce  that  he  will 
refuse  to  take  food.  The  blowing  in  of  orthoform,  the  instillation 
of  menthol,  the  insufflation  of  morphin,  dysphagia  tablets,  paint- 
ing with  cocain,  etc.,  very  frequently  fail,  in  the  ulcerative  form 
of  laryngeal  tuberculosis,  to  relieve  the  pain,  so  that  in  a  short 
time  after  the  onset  of  this  affection  one  can  do  nothing  for  the 
conditions. 

The  anesthesia  of  the  entrance  to  the  larynx,  by  Hoffman, 
through  injection  of  alcohol  in  the  superior  laryngeal  nerve,  at 
its  place  of  entrance  through  the  thyrohyoid  ligament,  has  given 
a  very  satisfactory  result  in  many  cases,  in  that  the  dysphagia 
diminishes  and  the  otherwise  rapid  inanition  is  hindered.  I  can, 
upon  the  basis  of  a  large  number  of  injections  made  in  very  sick 
tuberculous  patients,  warmly  recommend  this  treatment,  and  I 
would  like  to  emphasize  the  fact  that,  in  a  number  of  cases,  I  was 
able  to  induce  an  anesthesia  persisting  through  many  weeks. 

The  pain  in  carcinoma  of  the  larynx  depends  upon  the  locali- 
zation of  the  tumor.  Extralaryngeal  tumors,  lying  in  the  region 
of  the  aditus,  give  rise  very  early  to  pain  on  swallowing,  while  in 
intralaryngeal  tumors  pain  may  not  appear  for  a  long  time. 
There  are,  then,  because  of  the  overgrowth  of  the  tumor,  severe 
disturbances  of  swallowing.  One  may  say,  in  regard  to  the  early 
diagnosis  of  carcinoma  of  the  larynx,  that  the  first  symptom  of  the 
extralaryngeal  carcinoma  is,  as  a  rule,  dysphagia  and  that  the  first 
symptom  of  intralaryngeal  carcinoma  is  hoarseness.  Yet  there 
are  cases,  to  which  Leopold  von  Schroetter,  especially,  has  drawn 
attention,  where,  in  spite  of  severe  destruction  in  the  region  of  the 
aditus,  pains  are  entirely  absent.  However,  these  are  very  rare. 
The  explanation  lies  in  the  fact  that  in  these  cases  there  are  sen- 
sory disturbances  in  the  area  of  distribution  of  the  superior  laryn- 
geal nerve.  Generally  the  pains  are  spontaneous,  on  deglutition 
as  Avell  as  upon  external  pressure.     The  pain  in  carcinoma  of  the 


PAIN   IN  THE   LARYNX  359 

larynx  is  explained  through  the  simultaneous  occurrence  of  in- 
flammatory conditions,  necrosis  formation,  and  hardening,  while 
the  pressure  symptoms,  or  the  propagation  of  the  irritability, 
occur  from  the  involvement  of  the  superior  laryngeal  nerve.  Often 
the  pains  assume  the  form  of  neuralgia,  and  radiate  as  lightning 
pains  into  the  region  of  the  nervus  auricularis  vagi. 

Laryngeal  neuralgia  is  infrequent,  and  is  observed  in  hys- 
terical and  neurasthenic  subjects.  The  neuralgia  often  radiates 
to  the  ear  and  frequently  reaches  an  unbearable  severity.  Lemon 
has  reported  a  case  in  which  a  patient,  in  the  climacteric  period, 
threatened  suicide  if  freedom  from  her  raging  pain  was  not 
obtained  for  her.  In  other  patients,  when  the  pain  occurs  on 
speaking,  it  shows  itself  as  a  typical  phonophobia.  Finally,  it  is 
mentioned  that,  in  these  glottis  spasms  which  we  so  frequently 
find  in  tabes  dorsalis,  the  so-called  laryngeal  crises,  hyperesthesia 
and  hyperalgesia,  in  the  form  of  sensory  aura?,  are  often  found, 
and  introduce  the  cramp  crises.  The  explanation  of  these  forms 
of  pain  is  probably  analogous  to  that  of  the  adduction  spasm,  they 
being  due  to  an  irritation  of  the  sensory  sphere.  The  typical 
attack  in  such  cases  occurs  as  a  peculiar  sensation  in  the  larynx, 
in  the  form  of  a  sticking,  burning,  lightning  pain,  accompanied 
by  states  of  anxiety  or  feelings  of  sultocation,  after  which  the 
spasm  of  the  glottis  follows. 


CHAPTER  XIX 

ABDOMINAL  PAIN 

Classification. — There  are  two  classes  of  abdominal  pain :  sub- 
jective and  objective. 

The  subjective  pains  belong  to  the  class  of  symptoms  usually 
termed  hysterical.  For  their  production  no  organic  basis  can  be 
found.  They  seem  to  be  due  to  the  awakening  into  consciousness 
of  sensation-phenomena  stored  away  in  the  subconscious  mind. 

Objective  pains,  on  the  other  hand,  have  for  their  produc- 
tion either  some  definite  pathologic  change,  functional  or  or- 
ganic, or  a  changed  relationship  of  the  organs  as  a  whole  to  other 
adjacent  organs,  such  as  occurs,  for  example,  in  a  ptosis  of  the 
stomach  or  of  the  liver. 

Subjective  pain,  in  relation  to  the  abdominal  viscera,  will 
not  be  considered  here.  It  has  already  been  discussed  in  the 
opening  chapters. 

Objective  abdominal  pain  is  important  because  of  its  rela- 
tionship to  changed  iDathology  in  the  abdomen.  It  may  be  due  to 
a  lesion  of  the  skin,  the  subcutaneous  tissues,  the  muscle,  the  peri- 
toneum, or  the  viscera. 

The  SKIN  is  frequently  painful,  especially  when  it  is  the  seat 
of  some  inflammatory  skin-disease,  such  as  erysipelas.  It  is  also 
very  painful  in  certain  nerve  lesions,  as  neuritis,  or  herpes. 

The    MUSCULAR    LAYER    OF    THE    ABDOMINAL    WALL    is    Credited 

by  Mackenzie  with  pain  production.  He  says :  ^'It  is  the 
muscular  layer  in  the  abdominal  wall  which  is  so  exquisitely  ten- 
der in  all  affections  of  the  viscera,  giving  rise  to  severe  reflex 
musculovisceral  pain,  as  in  appendicitis.  Also,  the  abdominal 
360 


OBJECTIVE    ABDOMINAL    PAIN  361 

muscles  above  the  lesion  are  in  a  state  of  contraction  and  are 
extremely  tender  to  pressure."  That  Mackenzie  erred  and  exag- 
gerated the  importance  of  the  muscular  coat  in  pain  production  is 
proved  by  the  researches  of  Lennander  and  others.  Later,  Mac- 
kenzie (862)  himself,  modifying  his  previous  statements,  says 
that  the  subperitoneal  layer  is  the  most  sensitive,  and,  in  confirma- 
tion of  his  views,  quotes  Ranstrom,  who  has  found  many  nerves 
and  nerve  endings  in  this  layer.  The  nerves  are  derived  from 
those  supplying  the  muscular  layer.  All  direct  painful  muscular 
lesions  in  the  abdominal  wall  are  the  result  of  inflammation, 
neuritis,  neuralgia,  myalgia,  or  new  growths. 

Inflammation  in  the  abdominal  ivall  is  accompanied  by  all 
the  signs  and  symptoms  usually  associated  with  inflammation  in 
general,  such  as  swelling,  redness,  heat  and  loss  of  function.  The 
pain  is  of  a  throbbing  character.  Tenderness  on  pressure  is  also 
present.  In  some  cases  the  inflammation  precedes  abscess  forma- 
tion. Such  cases  are  described  by  Hitzrot  (337).  The  pain  was 
localized,  and  was  increased  on  assuming  the  erect  posture  and  on 
deep  pressure.  He  quotes  Fouquet  (370),  Sonnenberg  (371), 
Spellisy  (372),  Heller  (373)  and  Allison  (374),  who  have  all 
described  similar  conditions. 

Neuralgia  of  the  nerves  of  the  abdominal  wall  occurs  and  is 
frequently  observed  with  or  after  infectious  diseases.  When  it  is 
present  the  skin  is  exquisitely  tender,  and  is  very  painful  to  the 
,  pressure  made  by  pinching  it  between  the  fingers.  In  this  it  dif- 
fers from  peritonitis,  in  which  the  skin  is  not  so  tender,  and  the 
pain  is  produced  only  on  deep  pressure.  In  neuritic  lesions  of 
the  abdominal  walls  the  pain  is  usually  unilateral.  When  the 
lumbar  nerves  are  affected,  the  pain  is  commonly  felt  in  the 
hypogastric  region,  a  little  to  one  side  of  the  median  line.  In 
this  area,  too,  there  is  localized  tenderness  on  pressure.  Tender 
spots  are  also  found,  one  a  little  to  the  outside  of  the  first  or 
second  lumbar  vertebra,  and  another  immediately  above  the  crest 
of  the  ilium.  In  women,  who  are  by  far  the  greatest  sufferers 
from  this  disease,  there  is  also  sometimes,  about  the  middle  of 
the  Fallopian  tube,  a  spot,  pressure  upon  which  causes,  pain  to 


362  ABDOMINAL    PAIN 

be  referred  to  the  anterior  abdominal  wall.  There  is  another 
sjjot  above  the  uterus.  In  men,  points  here  and  there  on  the  scro- 
tum are  found  which  are  painful  to  the  touch.  These  points  of 
tenderness  serve  as  characteristic  signs  of  neuralgia.  Neuralgia 
is  to  be  diagnosed,  not  only  from  colic,  but  from  lumbago  and 
rheumatism  of  the  abdominal  walls.  Diagnostic  sigiis  of  neu- 
ralgia are  the  absence  of  fever  and  the  relief  which  is  sometimes 
produced  by  pressure  and  ordinary  antineuralgic  remedies. 

Neuritis  of  the  intercostal  nerves  is  fairly  frequent.  This 
frequency  occurs  because  these  nerves  are  particularly  subject  to 
the  deleterious  influences  of  cold  and  traumatism,  on  account  of 
their  exposed  position.  (For  a  more  complete  description  see 
under  Neuritis.) 

Myalgia  is  closely  related,  as  far  as  etiology  is  concerned,  to 
the  neuralgias.  It  seems  to  be  due  in  very  many  cases  to  a  dis- 
ordered metabolism.  This  is  the  condition  to  which  the  term 
"rheumatism  of  the  abdominal  wall"  is  given  wrongly. 

New  growths,  such  as  cysts  and  various  kinds  of  tumors,  may 
occur  in  the  abdominal  wall.  If  of  slow  development,  they  cause 
no  great  inconvenience,  for  by  their  slow  increase  in  size  they 
gradually  push  the  surrounding  structures  to  one  side,  and  the 
tissues  learn  to  accommodate  themselves  to  the  presence  of  the 
foreign  occupant.  Should  nerves  be  incorporated  in  the  growth, 
and  pressure  be  exerted  upon  them,  pain,  generally  of  an  aching 
character,  results.  This  pain  may  be  localized  to  the  region  of 
the  growth,  or  may  be  referred  to  some  distance  in  an  area  to 
which  the  affected  nerve  is  distributed.  The  size  of  the  growth 
bears  no  relationship  to  the  amount  of  pain  which  it  may  pro- 
duce, the  smaller  growths  producing  as  much,  if  not  more,  pain 
than  many  of  the  larger  ones.  The  amount  of  the  pain  depends 
upon  the  rapidity  of  the  growth,  the  number  of  nerves  incorpo- 
rated in  it,  and  the  pressure  exerted  upon  them  by  the  inclosing 
tissues. 

Peritoneum. — According  to  Mackenzie,  the  peritoneum  is 
devoid  of  pain  nerves.  However,  he  claims  that  the  subperi- 
toneal layer  is  plentifully  supplied  with  pain  nerves,   and  that 


OBJECTIVE    ABDOMINAL    PAIN  363 

it  is  liere  tliat  the  painful  impulses  arise.  In  its  lack  of  pain 
perception,  the  peritoneum,  he  says,  is  not  unique  among  serous 
membranes,  for  this  is  characteristic,  he  holds,  of  all  serous  mem- 
branes, since  they  have  no  nerves  which  will  transmit  pain  stimuli 
of  the  kind  foimd  in  the  skin,  the  tunica  vaginalis  testis  being  the 
.only  serous  membrane  which  is  sensitive  to  the  usual  tests  for 
pain  sensibility.  This  is  due  to  the  fact  that  the  tunica  vaginalis 
testis  is  innervated  by  a  cerebrospinal  nerve,  the  genital  branch  of 
the  genitocrural  nerve. 

Mackenzie's  proofs  that  serous  membranes  are  not  the  seat  of 
pain  production  were:  (1)  that  the  abdominal  wall  is  very  tender 
in  certain  visceral  colics  in  which  there  is  no  inflammation  of  the 
peritoneum;  (2)  the  skin  of  the  abdominal  wall  generally  is  not 
so  sensitive  in  visceral  lesions,  for  it  can  be  pinched  between  the 
fingers  without  producing  pain;  but  if  the  muscles  are  grasped 
between  the  thumb  and  fingers,  acute  pain  is  felt;  (3)  direct 
stimulation  of  exposed  pleura,  pericardium,  and  peritoneum  does 
not  produce  pain.  That  this  is  not  absolutely  true  will  be  shown 
in  the  discussion  of  j)eritonitis. 

The  peritoneum  is  the  lining  membrane  of  the  abdominal 
cavity.  It  consists  of  two  layers:  (1)  the  visceral  layer,  -which 
covers  the  inclosed  organs,  and  (2)  the  parietal,  which  lines  the 
external  wall  of  the  cavity.  It  has  been  held  by  many  that  the 
visceral  peritoneum  is  without  pain  sensibility,  but,  as  will  be 
pointed  out,  much  depends  upon  the  type  of  stimulus.  The  adequate 
stimulus  in  the  viscera  is  deep  pressure ;  that  largely  produced 
by  tension.     It  is  the  type  of  deep  sensibility  described  by  Head. 

It  was  the  belief  of  Lennander  that  "all  painful  sensations 
within  the  abdominal  cavity  are  transmitted  only  by  means  of 
the  parietal  peritoneum  and  its  subserous  layer,  both  of  which 
are  richly  supplied  with  cerebrospinal  nerves  around  the  whole 
of  the  abdominal  cavity,  with  the  exception  of  a  small  area  in 
front  of  the  vertebral  column  lying  below  the  crura  of  the  dia- 
phragm, and  between  the  two  chains  of  sympathetic  nerves." 
Here  he  found  no  cerebrospinal  nerves,  but  only  nerves  running 
more  or  less  transversely  between  the  two   sympathetic  chains. 


364  ABDOMINAL    PAIN 

He  found  that  within  this  area  the  patient  does  not  respond  to 
hard  pressure  with  a  finger,  or  with  an  instrument,  and  that 
stretching  of  the  mesenteric  attachments  at  this  point  is  not  pain- 
ful. So  far  complete  uniformity  does  not  exist  as  to  presence  or 
absence  of  pain  sensibility  in  the  peritoneum,  though  many  ob- 
servers are  in  accord  with  the  dedu-ctions  of  Lennander. 

Diseases  of  the  peritoneum  producing  pain  are  inflammations, 
hemorrhage,  and  new  growths. 

Inflammations  of  the  Peritoneum. — Inflammation  of  the  peri- 
toneum (peritonitis)  causes  pain  only  when  acute.  The  chronic 
inflammatory  forms,  as  a  rule,  produce  but  little  pain,  except 
as  the  result  of  adhesion  formation.  The  seat  of  the  pain  in  peri- 
tonitis, according  to  INIackenzie,^  is  not  in  the  peritoneum  itself, 
but  in  the  subperitoneal  tissue.  This  layer  is  exquisitely  tender, 
and  Ramstrom  found  it  richly  supplied  with  nerve  fibers,  which, 
in  turn,  are  derived  from  the  nen'^es  of  the  anterior  abdominal 
wall.  These  nerves  also  supply  the  abdominal  muscles,  and  thus 
one  can  account  directly  for  the  reflex  rigidity  of  these  muscles 
(supplied  by  the  same  nerves)  when  the  peritoneum  is  affected. 

In  some  cases,  however,  acute  peritonitis  may  be  present  with- 
out producing  any  pain  phenomena.  This  is  especially  so  in  the 
violent  cases  in  which  the  abdomen  contains  a  quantity  of  pus 
(Bradford,  207).  This  lack  of  pain  may  be  due  to  the  rapid 
destruction  of  the  nerve  endings,  or  to  the  impairment  of  their 
efficiency.  Such  a  state  is  frequently  met  with  in  puerperal 
sepsis. 

However,  in  all  cases  of  sudden,  sharp,  exacerbating  pain, 
with  rigidity  of  the  abdominal  muscles,  generalized  tenderness, 
normal  or  subnormal  temperature,  and  a  rapid,  rising  pulse,  peri- 
tonitis should  be  thoughtfully  considered  (Richardson,  23). 
Should  the  pain  be  dull  and  aching,  the  sub-peritoneal  connective 
tissue  is  probably  involved. 

1  It  is  also  claimed  by  Mackenzie  that  the  parietal  peritoneum  or  rtseft 
is  insensitive  to  pain;  that  it  is  the  tiny  nerve  filaments,  distributed  in  the 
cellular  tissue  subjacent  to  the  peritoneum,  which  are  extremely  sensitive, 
and  that  the  slightest  traction  or  pressure  on  them  produces  the  most  ex- 
cruciating pain, 


INFLAMMATIONS    OF    THE    PERITONEUM  365 

Tuberculous  Peritonitis.^Iii  cases  of  tuberculous  origin 
pain  may  be  an  almost  negligible  symptom.  Tbe  exceptions  are 
those  conditions  in  which  adhesions  have  developed,  or  in  which 
the  tuberculous  material  has  become  encysted  and  has  ulcerated 
or  suppurated.  This  gives  rise  only  to  a  little  pain  on  walking, 
while  obliterative,  encysted,  or  sciatic  forms  may  cause  no  pain 
(Rolleston,  619).  In  case  of  tuberculous  peritonitis  Bainbridge 
has  found  that  the  injection  of  oxygen  into  the  peritoneal  cavity 
will  relieve  the  pain.  This  may  be  due  to  the  separation  of  the 
two  adjacent  surfaces  from  each  other,  possibly  to  an  anesthetic 
action  of  the  oxygen. 

A  common  source  of  mistakes  in  the  diagnosis  of  peritonitis 
is  the  confusion  of  referred  pain  with  that  due  to  peritonitis. 
Diagnostic  criteria  between  the  two  conditions  are:  (1)  The  ten- 
derness of  referred  pain  is  produced  by  slight  stimulation  of  the 
skin  and  the  subcutaneous  tissues,  and  seems  to  be  relieved  by 
deep  pressure;  (2)  the  exact  opposite  is  found  to  be  the  case  in 
peritonitis,  deep  pressure  being  painful,  while  light  pressure  is 
not  so  distasteful;  according  to  Lennander  (618),  the  boundaries 
of  the  hyperesthetic  zones  in  peritonitis  can  be  mapped  out 
almost  to  a  centimeter;  (3)  in  peritonitis  proper  there  is  gener- 
ally no  referred  pain;  this  is  given  by  Moullin  (226)  as  a  good 
indication  that  no  other  viscera  are  involved,  for  as  soon  as  the 
viscera  become  involved  hyperalgesia  is  present;  (4)  in  perito- 
nitis the  abdominal  reflexes  are  not  exaggerated,  while  in  referred 
pain  they  are  exaggerated. 

Should  a  peritonitis  be  sudden  in  onset,  as  is  the  case  in  the 
perforation  of  an  ulcer  of  the  stomach,  or  of  the  duodenum,  the 
pain  is  generally  paroxysmal  and  is  most  severe.  When  the  car- 
diac end  of  the  stomach  is  involved,  the  pain,  as  a  rule,  is  under 
the  left  scapula.  When  the  pyloric  end  is  the  part  affected,  the 
pain  is  under  the  right  scapula  (Mayo  Robson,  619). 

If  the  abdominal  pain  is  associated  with  tenderness  it  is  neces- 
sary to  distinguish  between  inflammation  of  the  constituents  of 
the  wall  (skin,  muscle,  peritoneum),  neuralgia  and  neuritis.  In 
peritonitis  pain  is  produced  only  on  the  making  of  pressure  on  the 


366  ABDOMINAL   PAIN 

abdominal  wall,  while  in  neuralgia  or  myalgia  it  may  be  necessary 
to  pinch  the  skin  or  muscle  between  the  fingers  before  pain  is 
elicited.  If  peritonitis  is  present  there  is  also  pain  on  the  patient 
taking  a  deep  breath,  upon  the  making  of  a  pelvic  examination, 
and  also,  in  some  cases,  upon  flexion  of  the  bod}'.  Should  the  pel- 
vic peritoneum  be  inflamed,  pain  is  produced  when  the  inflamed 
jDcritoneum  is  pressed  ujion  by  the  examining  finger.  Tilting  up 
of  the  uterus  by  pressure  on  the  cervix  will  always  cause  pain, 
and  pain  is  also  present  on  making  deep,  and,  if  the  peritonitis 
is  severe,  light  pressure  low  do"\vn  on  the  abdominal  wall.  Biman- 
ual externovaginal  examination  will  cause  pain  if  the  peritoneum 
at  the  brim  of  the  pelvis  is  inflamed.  Defecation,  micturition  and 
sexual  connection  (if  a  female)  are  also  painful.  The  visceral 
peritoneum  is  different  from  the  parietal  peritoneum  in  that  pain 
is  not  produced  by  pressure  wpon  it ;  but  it  is  very  sensitive  to 
traction  made  upon  it  through  the  mesentery.  The  pain  produced 
by  this  traction  is  interpreted  as  coming  from  some  zone  of  the 
body  and  not  from  the  affected  viscera.  This  Mackenzie  ex- 
plained by  the  fact  that  the  abdominal  viscera  are  supplied  en- 
tirely by  the  sympathetic  system,  which  has  no  sensory  nerves. 
When  it  is  irritated  its  nerves  carry  impulses  to  the  cord  cells  and 
stimulate,  in  turn,  adjacent  sensory  cells  to  activity,  thus  caus- 
ing a  painful  impulse  to  be  conveyed  to  the  brain.  This  impulse 
is  projected  as  if  coming  from  the  peripheral  distribution  areas 
of  the  sensory  nerves,  whose  cells  are  stimulated. 

Chronic  peritonitis  is  somewhat  different  from  the  acute, 
and  is  much  slower  in  onset  and  duration.  The  pain  is  due  to 
the  following  causes : 

(1)  Traction  and  pull  from  adhesions,  the  result  of  the 
chronic  inflammatory  process. 

(2)  Distention  of  the  bowel  from  gas  or  fecal  matter,  owing 
to  obstruction  of  the  lumen  by  adhesions  which  may  be  old  or 
recent. 

(3)  Localized  collections  of  fluid  encysted  by  the  peritoneal 
adhesions.  These  localized  collections  may  be  either  serum,  pus, 
or  blood.     After  the  fluid  contents  have  reached  a  certain  stage. 


NATURE    OF   PAIN   FROM   ADHESIONS  367 

thej  begin  to  exert  pressure  or  traction  on  the  adjacent  structures, 
and  thus  cause  the  pain.  In  some  cases  of  slow,  insidious  peri- 
tonitis, especially  those  of  tuberculous  origin,  there  may  be  no 
pain  of  any  moment  until  adhesions  form,  when  pressure  causes 
tension  pains. 

The  location  of  the  pain  may  give  an  indication  of  the  viscera 
which  are  involved  by  the  adhesions  (for  the  points  of  reference 
on  the  abdominal  wall  of  visceral  pain,  see  Viscera,  Chapter  XX, 
pp.  383-389). 

Hemorrhage. — -In  sudden,  severe  hemorrhage  into  the  abdomi- 
nal cavity,  such  as  occurs  in  the  rupture  of  an  extrauterine  preg- 
nancy, pain  is  present ;  but  in  hemorrhages  following  operation, 
pain,  as  a  rule,  is  absent.  This  latter  condition  can  probably  be 
accounted  for  by  the  previous  insult  to  the  peritoneum  by  the 
operative  procedures,  wdth  the  consequent  reduction  in  its  sensi- 
bility. 

In  some  cases  of  excessive  dilatation  of  the  abdomen  from 
tympanites,  or  from  obstruction,  the  abdominal  tenderness  is  ex- 
cessive, but  at  the  same  time  the  pulse  and  temperature  sfre  not 
of  a  peritoneal  character. 

Tumors  of  the  Peritoneum. — Tumors  of  the  peritoneum  gener- 
ally cause  pain.  "When  they  are  in  the  back,  and  lie  posterior  to 
the  peritoneum,  they  frequently  cause  pain  by  the  pressure  which 
they  exert  upon  the  spinal  nerves.  This  pain  is  referred  to  the 
back  or  along  the  course  of  the  nerves  of  the  lumbosacral  plexus. 
It  must  be  diagnosed  from  the  pains  due  to  aneurysm,  vertebral 
caries,  or  spinal  tumor. 

Nature  of  Pain  from  Adhesions. — As  an  end  result  of  nearly 
all  processes,  both  inflammatory  and  otherwise,  in  the  abdominal 
cavity,  is  adhesion  formation.  These  adhesions,  as  a  rule,  cause 
pain,  wdiich  is  generally  localized  to  one  spot,  at  which  point  pain 
is  also  produced  by  pressure. 

The  pain  may  come  in  paroxysms ;  when  it  does  so,  the 
attacks  resemble  each  other,  and  have  the  same  train  of  symptoms. 
The  pain  also  is  influenced  by  certain  muscular  movements  or 
positions  of  the  body,  and  may  be  lessened  or  increased  by  mov- 


368  ABDOMINAL   PAIN 

ing  about  or  by  turning  over  from  one  side  to  the  other.  It  is 
increased  by  peristalsis,  especially  if  the  adhesions  are  between  the 
stomach  or  intestine  and  the  anterior  abdominal  wall.  When  the 
adhesions  are  between  the  stomach  and  the  anterior  abdominal 
wall,  the  pain  is  often  increased  after  eating.  Adhesion  pain 
is  also  increased  by  tension  of  the  anterior  abdominal  wall,  when, 
by  a  backward  motion  of  the  upper  part  of  the  body,  or  hyper- 
extension  of  the  thigh,  the  distance  between  the  ribs  and  the  pelvic 
bones  becomes  increased.  In  such  cases  the  recti  muscles  become 
rigid  and  traction  is  made  on  the  adhesions.  The  magnitude  of 
the  pain  varies  indirectly  as  the  area  of  the  adhesion.  This  is 
due  to  the  fact  that,  in  extensive  adhesions,  the  traction  upon  the 
parietal  peritoneum  is  not  limited  to  any  one  spot,  as  it  is  in 
very  limited  adhesions,  but  is  spread  out  over  a  large  area,  and 
consequently,  not  being  perceived  acutely  in  any  single  nerve 
distribution,  is  felt  rather  as  a  dull,  dragging  pain,  instead  of  a 
sharp,  pulling  one. 

Increased  tension  of  the  anterior  abdominal  wall  also  causes 
pain  is  cases  of  hernia  in  which  stretching  of  the  omentum  is 
probably  present. 

Adhesions  pulling  upon  the  peritoneum,  as  a  rule,  cause 
greater  pain  if  there  is  a  sudden  variation  in  the  traction,  such 
as  can  occur  when  a  hollow  viscus  of  changing  size  and  position, 
such  as  the  stomach,  is  attached  to  the  anterior  abdominal  wall. 
In  this  case  the  pain  depends  upon  the  variations  in  the  force  of 
the  traction,  depending  upon  the  amount  of  the  stomach  contents 
and  the  state  of  its  functional  activity. 

Adhesions  between  the  omentum  and  the  anterior  abdominal 
wall  are  a  frequent  cause  of  pain,  because  the  bowel  places  the 
omentum  on  the  stretch,  by  forcing  itself  into  the  pocket  between  it 
and  the  anterior  abdominal  wall.  Adhesions  between  the  viscera 
if  not  connected  with  the  anterior  abdominal  wall  cause  no 
pain  unless  traction  or  pressure  is  made  upon  the  mesentery  or 
other  pain  sensitive  organs,  by  the  changing  relationships  or  the 
hindered  movements  of  the  adherent  viscera. 

In  this  connection  it  might  be  well  to  consider  the  causes  of 


NATURE    OF    PAIN   FROM    ADHESIONS  369 

abdominal  adhesions.  Tliej  are  the  following:  (1)  tumors,  which 
form  adhesions  because  of  the  pressure  on,  and  consequent  trau- 
matism of,  adjacent  organs;  (2)  intestinal  ulceration,  which  is 
not  an  active  cause  of  adhesion  formation  unless  perforation  has 
occurred;  (3)  after  laparotomies  adhesion  between  the  omentum 
and  parietal  peritoneum ;  and  (4)  inflammation,  particularly  that 
due  to  or  associated  with  tuberculosis.  Inflammatory  lesions  of 
the  gall-bladder  are  also  potent  causes  of  abdominal  adhesion  for- 
mation. 

Abdominal  adhesions,  according  to  Cumston,  are  divided  into : 

(1)  A  gastric  group,  including  cholelithiasis;  ulcer  of  the  stom- 
ach and  duodenum ;  traumatism  to  the  stomach,  liver,  pancreas, 
and  duodenum ;  carcinoma  of  any  of  the  above-mentioned  organs ; 

(2)  the  intestinal  group,  which  is  particularly  associated  with 
the  appendix  and  the  siginoid;  (3)  the  pelvic  group,  which  in- 
cludes lesions  of  the  tubes,  ovaries,  and  the  uterus ;  and  (4)  the 
peritoneal  group,  including  all  lesions  in  which  primarily  the 
peritoneum  is  involved,  as  in  tuberculous  peritonitis. 

Gastric  Adhesions. — The  diagnosis  of  adhesions  may  be  made 
easier  if  it  is  borne  in  mind  that  when  adhesion  of  a  viscus  to 
the  anterior  abdominal  wall  or  to  another  organ  occurs,  pressure 
or  traction  on  the  abdominal  wall,  so  made  that  it  will  tend  to 
separate  the  two  adhering  surfaces,  will  produce  considerable  pain. 
Thus,  in  gastric  adhesions,  if  pressure  is  made  on  the  anterior 
abdominal  wall  in  an  upward  direction,  from  the  region  of  the 
lower  border  of  the  stomach,  the  pain  which  is  present  on  ordinary 
manipulations  is  greatly  increased.  If  the  adhesions  are  on  the 
right  or  on  the  anterior  border  of  the  stomach,  pressure  made  over 
the  epigastrium  will  cause  the  pain  to  shoot  out  from  the  right 
over  the  area  of  the  adhesions.  If  they  are  on  the  posterior  gastric 
wall,  pressure  over  the  first  and  second  lumbar  vertebrae  will  often 
cause  pain.  Adhesions  between  the  anterior  abdominal  wall  and 
stomach  are  not  so  frequent,  and  are  very  apt  to  be  confused  with 
gastric  ulcer.  Pain  due  to  intestinal  adhesions,  as  a  rule,  is  sud- 
den and  acute,  and  is  the  result  of  stenosis  of  the  gut  by  the  ad- 
hesions; generally  it  is  of  short  duration,  disappears  as  quickly 


370  ABDOMINAL   PAIN 

as  it  came,  and  is  frequently  followed  by  a  discbarge  of  fluid  feces 
or  flatus. 

Intestinal  Adhesions. — An  interesting  case  of  intestinal  adhe- 
sions  is  that  of  a  young  lady,  whose  history  is  as  follows : 

Nearly  two  years  before  admission  to  the  hospital  she  began 
having  acute  pains  in  the  abdomen,  of  a  spasmodic  character. 
During  the  past  year  these  have  become  more  frequent  and  are  ac- 
companied by  vomiting  and  eructations  of  gas.  The  attacks 
seem  to  be  brought  about  by  eating  indigestible  foods  and  exposure 
to  colds  and  dampness.  She  has  had  two  attacks  at  night  without 
apparent  cause.  The  menses  are  painless.  The  pains  are  always 
relieved  by  a  bowel  movement.  At  flrst  they  are  diffused  over  the 
abdomen,  but  soon  show  a  distinct  right-sidedness.  During  the 
last  attack  the  pain  was  mostly  toward  the  median  line,  slightly 
to  the  right. 

Operation  showed  the  cecum  and  adjacent  intestinal  coils  all 
matted  together  by  dense  adhesions,  which,  in  some  places,  were 
so  thick  that  they  had  to  be  cut  between  ligatures.  A  tumor,  cor- 
responding in  location  to  this  mass,  was  felt  on  the  right  side 
before  operation. 

Pelvic  Adhesions. — Pain  due  to  pelvic  adhesions  is  present 
(a)  at  stool,  (b)  during  micturition,  (c)  during  the  menses,  (d) 
on  moving,  (e)  on  subjecting  the  body  to  light  shock,  and  (f)  dur- 
ing coitus. 

A  case  in  point  is  that  of  Mrs.  X ,  whose  ovary  and  tube 

on  the  right  side,  and  appendix  were  removed,  drainage  being  in- 
serted because  of  the  pronounced  gangrenous  state  of  the  appendix. 
Some  weeks  after  operation  she  complained  of  aching  which  was 
worse  after  moving,  after  lying  down  at  night,  and  on  sweeping. 
This  aching  begins  in  the  lower  right  middle  region  anteriorly  and 
extends  through  to  the  back  in  the  lumbar  region. 

Another  case  is  that  of  Mrs.  Y ,  in  whom  pain  began  in 

the  right  side  and  was  constant.  She  had  a  feeling  as  though  a 
knot  were  being  tied  inside  her.  On  the  same  side  a  small  mass 
was  present.  A  year  previous  she  had  had  an  operation  per- 
formed, in  w^hich  the  ovaries  were  removed.     In  this  case  there 


NATURE    OF   PAIN   IN   HERNIA  371 

was  present  a  band  of  adhesion,  extending  from  the  uterus,  its 
appendages,  and  the  intestines,  to  the  lateral  pelvic  wall. 

General  Peritoneal  Adhesions. — If  the  pain  is  due  to  general- 
ized peritoneal  adhesions,  for  instance  those  following  a  gastric 
perforation,  it  is  often  present  after  eating,  and  comes  on  when 
the  stomach  is  full  or  when  the  patient  assumes  certain  positions. 

Pritchard  (620)  reported  a  case  of  abdominal  pain,  in  which 
the  diagTiosis  was  obscure,  but  on  operation  adhesions  were  found 
between  the  stomach  and  the  anterior  abdominal  wall.  iSTo  previ- 
ous symptoms  indicating  inflammation  could  be  elicited ;  no  ulcer- 
ated areas,  nor  indications  of  ulcer,  could  be  found.  After  re- 
viewing the  case  and  excluding  the  gall-bladder,  stomach,  or  duo- 
denal ulcers  as  the  cause  of  the  adhesive  formation,  Pritchard, 
because  of  the  presence  of  an  edema  of  the  lower  extremities, 
without  sufficient  cause  in  the  same  patient  a  year  or  two  previ- 
ously, offered  the  novel  explanation  that  the  edema  was  due  to 
neurotic  influences,  and  that  the  abdominal  adhesions  were  the 
result  of  the  same  influences  acting  in  the  abdominal  cavity  so  as 
to  produce  edema  of  the  stomach  and  duodenum,  and  consequent 
adhesive  formation. 

Nature  of  Pain  in  Hernia. — Because  of  the  mechanical  rela- 
tionship of  hernia  to  the  abdominal  structures,  it  has  been  thought 
wise  to  consider  it  in  this  section.  Pain  is  not  a  prominent 
symptom  of  simple  uncomplicated  hernia^  except  in  those  cases 
wherein  the  hernia  is  of  sudden  development.  Here  the  pain  is 
due  to:  (1)  Traction  on  the  mesentery.  This  occurs  in  the 
early  stages  of  the  condition.  Later  the  pain  is  due  to:  (2)  In- 
flammation of  the  bowel,  which  is  the  result  of  deficient  circula- 
tion, edema,  and  the  presence  of  toxins.  This  inflammatory 
process  causes  the  contents  of  the  hernial  sac  to  swell,  and,  if  the 
neck  is  small,  the  hernia  becomes  strangulated,  and  the  traction 
and  pull  upon  the  involved  mesentery  are  increased.  The  inflam- 
matory process  may  also  extend  to  the  parietal  peritoneum,  and 
to  the  pain  of  the  traction  there  is  also  then  added  the  pain  of 
the  peritoneal  irritation.  (3)  Peritoneal  irritation.  The  inflam- 
mation may  progl'ess  to  such  an  extent  that  adhesions  finally  form 


372  ABDOMINAL   PAIN 

between  the  peritoneum  and  the  bowel,  and  then  every  movement 
may  be  capable  of  producing  pain  of  a  dull,  dragging  character. 
Thus  pain  of  hernia  may  be  due  to  involvement  of  the  mesentery, 
the  bowel,  or  the  peritoneum. 

The  mesentery  as  a  factor  in  the  pain  production  is  generally 
of  little  moment  unless  the  onset  of  the  hernia  is  sudden,  when 
there  is  present,  in  the  majority  of  cases,  a  severe,  dragging  pain, 
most  frequently  about  or  above  the  umbilicus,  if  the  hernia  is  of 
the  small  intestine ;  while  if  it  is  of  the  lower  bowel,  the  pain  or 
distress  is  generally  below  this  level.  The  mesentery  probably 
also  receives  a  few  iibers  from  the  cerebrospinal  system;  and, 
when  irritation  to  them  occurs,  the  resulting  pain  is  generally 
referred  to  their  somatic  distribution.  When  this  is  the  case,  the 
area  of  tenderness  and  of  subjective  pain  is  generally  outlined  by 
the  area  of  distribution  of  one  or  more  of  the  spinal  nerves. 

The  ilioinguinal  nerve  passes  out  of  the  abdomen  at  the  exter- 
nal abdominal  ring,  and  is  distributed  to  the  ilioinguinal  region 
of  the  upper  and  inner  part  of  the  thigh  to  the  scrotum  in  the 
male,  and  to  the  labium  in  the  female ;  hernia,  producing  pressure 
on  this  nerve,  causes  pain  to  be  felt  as  coming  from  these  parts. 

Bowel  pain  proper  differs  from  that  of  hernia,  in  that  the  pain 
sensation  is  due  to  the  carrying  of  stimuli  to  the  cord,  where  some 
of  the  cells  of  the  spinal  nerves,  being  stimulated,  give  rise  to 
pain  sensation,  which  the  brain  interprets  as  coming  from  the 
peripheral  distribution  of  these  fibers.  The  area  of  tenderness 
and  subjective  pain  felt  in  the  distribution  areas  of  these  fibers 
does  not  follow  the  plan  of  distribution  of  any  spinal  nerve  or 
nerves,  but  is  located  in  the  area  of  distribution  of  fibers  arising 
from  certain  cord  segments,  as  marked  out  by  Head.  The  points 
of  tenderness,  which,  in  many  cases,  bear  no  definite  relation  to  the 
lesion  causing  the  trouble,  are  but  the  maximal  points  of  tender- 
ness of  these  cord  segments.  If  the  hernia  is  in  the  small  intes- 
tine, the  most  common  site  of  the  referred  pain  is  in  the  region 
of  the  umbilicus,  while  in  involvement  of  the  large  bowel  the  pain 
is  located  as  being  below  this  point;  if  peritoneal  irritation  is 
present,  a  local  tenderness  is  felt  at  the  place  of  the  lesion.     A 


NATURE    OF    PAIN    IN    HERNIA  373 

part  at  least  of  this  bowel  pain  is  due  to  distention  of  the  involved 
portion  of  the  bowel  by  gas.  When  this  factor  is  present,  the 
pains  are  generally  paroxysmal,  occurring  at  the  time  of  the 
bowel  distention,  and  are  eased  as  soon  as  the  gas  and  the  fecal 
contents  have  passed  on ;  but  should  the  swelling  at  the  neck  of 
the  sac  increase,  the  hernia  then  becomes  strangulated,  and  to 
the  other  factors  producing  pain  is  then  added  a  third,  namely, 
peritoneal  irritation. 

In  peritoneal  irritation  the  pain  at  first  is  slight,  and  similar 
to  that  described  above ;  but  after  it  once  develops,  it  is  so  much 
more  severe  than  the  other  two  that  they  are  of  minor  importance. 
The  tissues  are  now  exquisitely  tender,  and  are  sensitive  to  the 
slightest  pressure.  It  is  at  this  stage  that,  in  case  of  femoral  or 
inguinal  hernias,  the  patient  instinctively  draws  up  and  rotates 
inward  the  leg  of  the  affected  side. 

The  omental  hernias  are  generally  not  very  painful,  because 
the  omentum,  of  itself,  has  little  pain  sensibility ;  but,  in  some 
instances,  as  in  a  case  of  ventral  hernia,  where  the  patient  had 
suffered  from  cramps  and  severe  abdominal  distress,  with  vomit- 
ing, an  operation  showed  a  small  omental  ventral  hernia  about 
two  and  one-half  inches  above  the  navel  and  a  little  to  the  left  of 
the  median  line.     There  was  no  localized  tenderness. 

Pain,  as  a  symptom  of  simple  uncomplicated  hernise,  is  gener- 
ally of  minor  importance.  Few  of  the  cases  of  hernia  are  acute 
in  their  onset,  most  of  them  being  the  gradual  development  of 
years ;  and  even  when  the  hernia  is  acute,  the  pain  symptoms  are 
not  of  special  diagnostic  importance,  only  in  so  far  as  they  indi- 
cate the  special  region  of  the  bowel  attacked,  and  the  magnitude 
of  the  involvement.  In  chronic  cases  there  may  be  a  smarting 
or  burning,  which  De  Garmo  thinks  most  likely  indicates  an 
omental  protrusion.  The  most  common  pain  is  of  a  dragging 
nature,  and  is  worse  in  the  evening  and  better  in  the  morning, 
because  during  the  night  the  intraabdominal  pressure  is  relieved.^ 

*  Sir  William  Bennett  {Lancet,  Feb.  2,  1907,  p.  270)  mentions  a  case  in 
which  the  hernial  sac  had  a  very  small  opening;  and  he  suggests  that  it  was 
due  to  the  accumulation  of  fluid  in  the  sac,  as  the  day  went  on,  which  caused 
the  pain  to  be  so  much  more  pronounced  toward  evening. 


374  ABDOMINAL   PAIN 

Anything  causing  a  rise  of  the  intraabdominal  pressure,  snch  as 
coughing,  sneezing,  straining,  or  lifting,  is  likely  to  produce  this  pain. 

Strangulated  hernia  generally  gives  rise  to  the  greatest  dis- 
tress, very  often  present  around  the  umbilicus,  and  when  this  is 
associated  with  vomiting  the  diagnosis  of  gall-stone  colic  or  gas- 
tritis is  very  apt  to  be  made,  and  the  hernial  condition  neglected, 
while  the  patient  goes  rapidly  on  to  his  death. 

In  some  cases  of  strangulated  hernia  the  pain  begins  about 
the  umbilicus,  and  thence,  as  the  severity  of  the  lesion  increases, 
radiates  to  the  region  of  the  strangulation. 

Umbilical,  hernia  is  generally  associated  with  considerable 
local  and  referred  pain,  most  of  which  is  probably  due  to  traction 
on  the  stomach  from  the  involved  omentum,  adhesions  existing  be- 
tween either  the  stomach  or  the  adjacent  omentum  and  the  an- 
terior abdominal  wall. 

In  inguinal  hernia  forcible  extension  of  the  thigh  is  painful. 
In  some  cases  of  inguinal  hernia,  also,  the  pain  may  be  felt  in 
the  epigastrium,  and  radiates  to  the  back,  as  in  a  case  reported  by 
Witherspoon  (125,  p.  219),  in  which  the  patient  complained  of 
pain  in  the  epigastrium  radiating  to  the  back,  and  of  tender  areas 
on  either  side  of  the  vertebral  column  opposite  the  eighth  and 
ninth  thoracic  vertebrae.  Abrupt  pressure  over  the  epigastrium, 
centrally,  and  to  either  side,  over  the  recti  muscles,  excited  severe 
paroxysms  of  pain.  Gradual  pressure  iva-s  well  home.  Operation 
relieved  the  condition. 

The  following  is  a  case  of  pain  due  to  inguinal  hernia. 

The  patient  complained  of  pain,  or  rather  of  a  dragging  sen- 
sation, running  from  the  region  of  the  pubic  spine  doAvnward  and 
inward  to  the  scrotum.  This  pain  was  made  worse  by  walking, 
by  lifting,  or  even  by  sitting,  and  was  eased  on  lying  down. 
He  would  be  all  right  in  the  morning,  but  as  the  day  wore  on  he 
would  become  so  ill  that  he  would  have  to  give  up  his  work,  which 
was  that  of  a  driver  on  a  grocer's  wagon.  On  releasing  the 
hernia,  the  pain  entirely  disappeared.  The  sac  did  not  seem  to 
be  adherent  to  the  surrounding  fascia. 

Stockton,  in  speaking  of  inguinal  hernia,  describes  a  condition 


NATURE    OF    PAIN    IN    HERNIA  376 

in  which  the  complaint  is  pain  generally  referred  to  the  lower 
quadrant  of  the  abdomen :  it  is  of  a  colicky  character,  and  is  some- 
times burning.  There  may  also  be  present  continuous  suffering. 
These  symptoms  are  relieved  when  the  patient  lies  down,  and  are 
increased  on  active  movements,  also  in  lifting.  They  appear  and 
disajjpear  at  irregular  intervals.  Examination  discloses  a  patu- 
lous internal  inguinal  canal,  not  large  enough  to  permit  a  well- 
marked  hernial  protrusion,  but  sufficient  to  cause  a  bulging  outward 
of  the  peritoneum,  which  is  made  worse  by  coughing  or  straining. 

Epigastric  Hernia. — Epigastric  hernias  sometimes  simulate 
gall-bladder  or  duct  disease,  or  even  a  gastric  disorder.  They 
are  to  be  differentiated  from  the  small  subcutaneous  tumors  found 
in  the  epigastrium,  and  are  due  to  the  protrusion  of  small,  fatty 
masses  through  openings  in  the  anterior  abdominal  wall. 

Hernias  of  the  anterior  abdominal  wall  sometimes  produce 
symptoms  of  pain  which  disappear  on  lying  doA\Ti.  Examination 
may  elicit  no  apparent  abnormality,  and  the  physician  is  at  a  loss 
to  account  for  the  persistent  cryptogenic  pain  which  recurs  so  regu- 
larly on  motion,  or  on  the  performance  of  tasks  involving  an  in- 
crease of  the  intraabdominal  pressure.  In  many  cases,  while  a 
superficial  examination  shows  nothing,  a  more  thorough  one  may 
reveal  some  slight  thickening,  or  some  little  localized  swelling  of 
the  abdominal  wall.  When  this  is  found,  hernia  should  be 
thought  of.  When  small,  there  are  no  absolute  diagnostic  criteria 
of  a  hernia  of  this  character;  but  if  it  is  large  and  reducible, 
the  gurgling  accompanied  by  the  disappearance  of  the  tumor  on 
reduction  indicates  the  condition.  McEwen  (919),  in  speaking 
of  small  umbilical  hernias,  with  a  very  narrow  and  distensible 
sac,  states  that  the  pain  (violent  abdominal  pain)  frequently 
comes  on  at  an  early  stage,  before  any  prominent  external  tumor 
has  appeared,  and  he  attributes  the  pain  in  such  cases,  in  part,  to 
the  cupping  of  a  portion  of  the  bowel  in  the  narrow  mouth,  and 
in  part  to  the  distention  of  the  narrow  mouth,  causing  pressure 
on,  and  irritation  of,  the  peripheral  nerves. 

The  j^ain  of  fe:moral  herxia  in  the  male  may  sometimes  be 
referred  to  the  penis. 


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376 


CHAPTER    XX 

PAIN  IN  ABDOMINAL  VISCEEAL  DISEASE 

History. — The  question  of  the  sensibility  of  the  abdominal 
viscera  is  one  which  has  been  much  discussed,  and,  at  the  present 
time,  it  cannot  be  stated  with  certainty  that  the  problem  has  been 
definitely  solved.  As  long  ago  as  1753  Haller  had  noted  that  he 
failed  to  obtain  evidence  that  the  internal  viscera  were  sensitive 
to  painful  stimuli,  but  it  has  become  increasingly  evident  that  the 
nervous  mechanisms  of  the  visceral  activities  are  exceedingly  mani- 
fold, and  that  no  adequate  explanation  of  their  functions  is  possi- 
ble without  a  searching  investigation  of  their  rich  nervous  supply. 
The  work  of  Lennander  and  Mackenzie  seemed  to  point  to  the 
fact  of  there  being  no  pain  fibers  in  these  nerves,  but  that  of  Ross, 
of  Kast,  and  Meltzer  has  shown  that  the  observations  of  previous 
experiments  were  faulty  and  that  the  ordinary  tests  which  they 
used  for  the  elicitation  of  pain  phenomena  in  the  viscera,  which 
were  the  same  as  those  used  to  elicit  pain  response  in  the  skin, 
were  not  suitable,  since  the  viscera,  because  of  their  structure  and 
position,  are  non-responsive  to  these  stimuli,  but  may  respond  to 
other  forms  of  stimuli  than  do  the  skin  and  mucous  membrane. 

The  ordinary  facts  of  digestion  prove  the  response  to  chemi- 
cal stimuli,  and  also  to  those  of  heat  and  cold,  and  it  is  becoming 
apparent  that  some  modification  of  the  earlier  views  must  take 
place. 

The  sensibility  of  the  abdominal  organs  has  been,  for  many 
years,  a  question  of  debate  between  two  opposing  schools,  the  one 
maintaining  that  the  abdominal  viscera  of  themselves  were  not 
capable  of  producing  pain  phenomena,  the  other  holding  that  they 
were.     Evidently  both  were  right  to  some  extent,  for  it  has  been 

377 


378  PAIN    IN    ABDOMINAL   VISCERAL   DISEASE 

found  that  organs  wliich  under  normal  conditions  do  not  produce 
pain  will,  when  inflamed,  give  rise  to  pain  phenomena  (Rosthorn). 
However,  in  many  cases  it  must  be  admitted  that  the  sensibility 
to  pain  shown  by  the  abdominal  organs  is  very  unusual,  for  in 
many  cases  operative  interference  may  be  undertaken  without 
excessive  pain  production,  ovariotomies  having  been  performed 
by  Riedel  (865)  and  Johnnen  without  any  especial  pain.  The 
uterus  is  painful  only  when  inflamed  (Bernard,  8G7).  All  varie^ 
ties  of  abdominal  operations  were  performed  by  Lennander  with- 
out pain  production,  except  when  traction  was  made  on  the  mesen- 
tery. 

For  a  better  understanding  of  pain   production   in  visceral 
disease,  it  may  be  well  to  review  the  innervation  of  the  abdominal 
viscera.     The  innervation  of  the  viscera  is  from  both  the  cerebro- 
spinal and  the  sympathetic  system.     The  cerebrospinal  or  medul- 
lated  fibers  are  carried  in  the  vagus  and  in  the  splanchnics,  and 
are  distributed  to  the  various  abdominal  plexuses.     Where  they 
finally  terminate  is  an  undetermined  question,  but  it  seems  likely 
that  they  end  in  the  mesentery.     The  sympathetic  has  its  own 
special  nerve  system — its  fibers  pass  on  farther  than  those  of  the 
cerebrospinal  system,   and   are  ultimately  distributed  to  the  ab- 
dominal organs,  whose  functional  activities  they  coordinate  and 
regulate.     They  consist  of  vasoconstrictor,  vasodilator,  motor,  and 
inhibitory  fibers,  etc.  (Tigerstedt).     They  originate  in  the  lateral 
horn  on  the  same  side  of  the  cord  in  which  they  are  found,  pass 
through  the  posterior  ganglion  into  a  nerve  trunk,  and  finally  end 
in  a  ganglion,  from  which  fibers  are  carried  to  the  ultimate  distri- 
bution  area.     These  ultimate  ganglion  cells  have  no  connection 
with  each  other.     All  the  sympathetic  fibers  do  not  arise  in  the 
cord,  many  of  them  arising  in  the  posterior  ganglia,  or  from  the 
abdominal  ganglia  themselves.      Mackenzie,  Peterson    (72),  and 
others  hold  that  the  sympathetic  system  is  oldest  in  origin,  and 
that  the  cerebrospinal  system  is  merely  an  outgrowth  of  the  sym- 
pathetic, and  has  been  built  up  for  its  protection.     This  may  be, 
as  remarked  by  Mackenzie,  the  reason  for  its  proneness  to  convey 
pain,  one  of  the  functionally  protective  sensations.     In  this  way 


COntlUNlCOTlNG  BR  10  VAC.Ui.OJHt»AL\,V 
ONLY  ON  THE  RIGHT    SIDE 

N.  SPLANCHNIC  MAJOR 

N.SPLANCHNIC  MIHOR 

COELIAC  GAN&LION 

COnnUNlCATm&BR.TO  UPPER  lUMBAROAHOLI* 

UPPER  tUMBAR  GANGLIA 

-^-_T0  PHRENIC  GANGLION 

^_^._T0   SUPRARENAL  GANGLION 
-^TORENALIS   GANGLION 


1 ^_^-tO  bPERMATIC  OR  OVARIAN  PLt!<.Ui 


CALL  BLADDER 

PYLORUS 

PANCREAS 

DUODENUM 

GREATEF 

OF  STOI 


TO  PLEX05 


PANCREAS 
DUODENUM 
5MALL  INTES. 
CAECUM 

ASCENDING  COLON 
LARGER  PART  OF 
ASCENDING  COLON 


TO  PLEXUS   GASTRICUS   Sl/PERIOR 

PLEXUS  GASTRIC  OV  THE  VA6US(BIGMT) 
LEb^ER  CURVATURE 


TO  PLEXUS  UIENALIS 


SPLEtN 
PANCREAS 
UNDUSOFTME  STOMACH 


PLEXUS  AORTICA    ABOOM. 


TO  PLEXUS   MESENTERICUS  INFERIOR 

RANSVERSE  COLON, DtSCENOING  COLON 
ilGMOlD 


SUPERIOR  HEMORRNOlOALNERve 
UPPER  PART  OF  RECTUM 


-HYPOGASTRIC  PLEXUS 


Fig.  81. — Scheme  of  Innervation  of  Abdominal  Viscera. 
The  above  diagrammatic  drawing  shows  the  reason  for  the  tendency  of 
diseases  of  the  gall  bladder,  pancreas,  duodenum,  the  pylorus  and  the 
greater  curvature  of  stomach,  to  cause  pain  on  the  right  side  of  the 
body;  while  lesions  of  the  lesser  curvature,  fundus,  spleen  and  pan- 
creas have  a  tendency  to  produce  pain  on  the  left  side  of  the  body. 
Drawing  modified  from  Spalteholz. 

379 


380  PAIN   IN   ABDOMINAL   VISCERAL   DISEASE 

it  guards,  against  injury,  the  internal  organs  supplied  by  the  sym- 
pathetic, "which  ordinarily  has  no  direct  pain-conducting  sensi- 
bility, as  such  is  generally  understood.     The  sympathetic  contains 
both  afferent  and  efferent  fibers,  but  it  is  only  the  afferent  which 
may,  under  unusual  circumstances,  be  concerned  in  the  conduction 
of  pain  stimuli.     Ordinarily,  these  nerves  are  incapable  of  con- 
veying impulses  which  are  interpreted  as  painful ;   but  under  cer- 
tain modifications,  such  as  are  produced  by  injury,  a  change  of 
irritability  may  take  place,'  so  that  stimuli  which  ordinarily  do  not 
produce  pain  now  give  rise  to  the  most  excruciating  agony.     Such 
modifications  have  been  observed,  especially  by  Buch  and  Macken- 
zie.     Buch,   on  correlating  the   researches   of  Wutzer,   Florens, 
Brochet,  Valentin  and  Longet  with  his  own  clinical  findings,  con- 
cluded that  a  normal  sympathetic  nerve  is  incapable  of  carrying 
pain-producing    stimuli ;     but    that,    when    inflammation    ensues, 
some  change  in  its  excitability  occurs,  so  that,  instead  of  the  dull 
perception,  which  it  previously  had,  it  acquires  an  exquisite  sensi- 
tiveness, so  that  pinching,  pressing  or  dragging  on  it  is  very  pain- 
ful.    This  increase  of  sensitiveness  can  also  be  produced  by  con- 
tinued electrical  stimulation,  or  by  stretching  of  or  pressing  upon 
the  nerve   (Lemmering).     Hitter,  after  experimenting  on  dogs, 
concludes  that  the  fibers  conveying  the  impulses  interpreted  as 
painful  run  in  the  nerves  distributed  to  the  blood  vessels,  for  he 
found  that  ligation  of  the  vessels  was  much  more  painful  than 
irritation  of  the  parietal  peritoneum  or  traction  on  the  mesentery. 
This  is  in  accord  with  the  statement  made  in  a  previous  chapter, 
to  the  effect  that  in  the  internal  organs  it  is  probable  that  the 
sensory  fibers  accompany  the  vasomotor  nerves.     Should  such  be 
the  case,  it  is  likely  that  the  pain-conveying  fibers  are  collected 
into  the  same  ganglia,  or  in  the  ganglia  associated  with  those  of 
the  vasomotor  nerves.     It  has  been  found  that  the  vasomotor  cen- 
ter for  the  stomach  and  upper  intestine  is  in  the  plexus  coeliacus 
(Buch,    171;     Pincus,    465;     Budge,    466;     Techlenburg,    467; 
Lowen,  468,  and  Boer)  while  Laignel  Levastine  located  the  vaso- 
motor center  for  the  liver  in  the  right  semilunar  ganglion,  and  the 
vasomotor  center  for  the  spleen  in  the  left  semilunar  ganglion, 


HISTORY  381 

and  the  vasomotor  center  for  the  small  intestine  and  the  upper 
part  of  the  large  intestine  in  the  superior  mesenteric  ganglion. 
From  the  association  of  the  vasomotor  and  sensory  fibers,  it 
would  seem  that  these  ganglia  also  are  the  sensory  centers  for  the 
dependent  organs.  Lennander,  however,  states  that  it  is  traction 
of  the  mesenterj'  which,  in  turn,  produces  pull  and  traction  on  the 
sensory  (cerebrospinal)  filaments  in  its  substance  that  produces  the 
visceral  pain.  The  apparent  discrepancies  between  the  statements 
of  Eitter  and  Lennander  may  be  due  to  the  fact  that  Hitter's  ob- 
servations were  made  during  experiments  on  animals,  while  Len- 
nander's  were  made  during  abdominal  operations.  On  one  fact 
all  observers  are  practically  in  accord,  and  that  is  that  the 
parietal  pe.ritoneum  is  very  sensitive ;  and  there  is  also  concord 
in  the  belief  that  the  viscera  themselves  are  but  slightly  sensi- 
tive to  pain.  These  latter  views  are  in  accord  with  observations 
of  physicians  from  time  immemorial.  Perhaps  the  oldest  exam- 
ple is  in  Xenophon's  "Anabasis,"  wherein  mention  is  made  of 
Nakarchos,  the  Arcadian,  being  wounded  in  the  abdomen  in  battle, 
and  coming  in  flight,  holding  his  entrails  in  his  hands.  Then,  as 
we  pass  down  the  ages,  here  and  there  examples  are  given  of  the 
insensitiveness  of  the  internal  viscera.  Haller,  about  one  hundred 
and  fifty  years  ago  (1753),  noticed  that  the  liver,  spleen,  kidneys, 
heart  and  lungs  possessed  little  sensibility ;  that  the  parietal  peri- 
toneum was  slightly  sensitive,  while  the  visceral  peritoneum  was 
entirely  without  sensation.  He  also  states  that  the  subcutaneous 
coat  is  very  sensitive,  while  the  mesentery  has  no  sensation.  In 
this  connection,  I  shall  quote  in  pxtenso  from  Meyers,  who  has  so 
well  described  the  progress  of  our  knowledge  in  this  direction.  He 
says  that  ''Bichat  noticed,  at  the  end  of  the  eighteenth  century, 
that  electrical,  chemical  and  mechanical  stimulation  of  the  organs 
supplied  by  the  sympathetic  system  do  not  produce  pain."  This 
agrees  with  the  clinical  findings  of  Prony  (343),  who  states 
(1821)  that  Bichat  had  seen  dogs  devouring  their  own  intestines 
and  tearing  their  own  peritoneum,  which  had  prolapsed  through 
abdominal  wounds.  Many  observations  have  been  made  on  man, 
seeming:  to  show  absolute  insensitiveness  of  the  abdominal  viscera 


382  PAIN    IN   ABDOMINAL   VISCERAL   DISEASE 

(Mitchell,  263,  in  the  year  1872 ;  Bier,  331 ;  Mackenzie,  332 ; 
Lennander,  380;  Ilofmeister,  869;  Gushing;  Block,  870;  Mitch- 
ell, 840;  Partsch,  871).^ 

The  absolute  reliability  of  these  deductions  has  been  ques- 
tioned by  Kast  and  Meltzer,  and  more  recently  by  Neuman.  Kast 
and  Meltzer  claim  that  the  insensitiveness  to  pain  present  in  the 
abdominal  viscera  under  local  cocain  anesthesia  is  due  to  the  gen- 
eral toxic  action  of  the  cocain,  which  so  reduces  the  sensitiveness 
of  the  internal  viscera  that  they  no  longer  respond  to  stimuli,  to 
which,  without  the  cocain,  they  would  respond  and  which,  being 
carried  to  the  cerebrum,  would  be  interpreted  as  pain.  These 
deductions  are  apparently  controverted  by  Mitchell  (155,  pp. 
200-201),  who,  under  hypodermic  subcutaneous  injection  of 
normal  salt  solution,  was  able,  after  the  peritoneum  had  been 
opened  and  the  intestine  delivered,  to  seize  it  with  a  clamp,  rub 
it  with  gauze,  and  prick  it  with  a  needle,  all  without  the  produc- 
tion of  pain. 

The  pain  sensations  from  the  abdominal  organs  are  probably 

*  It  is  claimed  by  Lennander  that  none  of  the  abdominal  viscera  is  sen- 
sitive to  pain,  and  that  when  pain  occurs  it  is  due  to  the  following  causes 
(given  by  Kast  and  Meltzer,  134,  pp.  1017-1019).  (1)  pressure,  sliding  or 
pulling  of  the  parietal  peritoneum;  (2)  pulling  of  the  mesentery,  and  thus 
irritating  the  posterior  wall  of  the  abdominal  cavity,  which  is  provided  with 
pain  fibers  derived  from  the  spinal  nerves;  (3)  lymphangitis  and  lymphaden- 
itis occurring  and  reaching  the  nerves  of  the  posterior  wall;  (4)  irritating 
toxic  products  or  chemicals,  like  HCl  in  gastric  ulcer,  reaching  the  lymphatics 
of  the  posterior  wall. 

Maunsell  Moullin  says  that  the  effect  of  traction  on  the  mesentery  is 
the  same,  whether  there  is  a  "  free  mesentery  or  whether  the  peritoneum 
is  reflected  from  the  sides  of  the  viscera,  leaving  a  portion  of  the  circumfer- 
ence of  the  bowel  attached  to  the  parietes  by  cellular  tissue"  (Moullin).  In 
this  case,  besides  the  stimulation  of  the  nerves  in  the  peritoneum,  there  would 
be  traction  upon  the  nerves  in  the  connecting  tissue.  These  nerves  are  de- 
rived directly  from  the  cerebrospinal  system,  and  any  traction  upon  them 
would  be  referred  as  pain  to  the  distribution  area  of  their  somatic  branches. 
It  is  a  well-known  fact  that  the  surfaces  of  the  internal  viscera  are  not 
painful  to  pressure,  pinching  or  squeezing,  nor  to  heat  and  cold.  Their 
only  function  is  reference  of  impulses  having  to  do  with  the  well-being  of 
the  organism;  and  in  cases  of  inflammation,  as  suggested  by  Lennander  (23), 
it  is  possible  that  toxins  may  be  carried  by  the  lymphatics  to  the  nerve  fila- 
ments, thus  rendering  them  more  sensitive,  so  that  they  respond  to  stimuli 
with  a  reaction  which  is  called  pain.  Inflamed  organs  are  slightly  more  sensi- 
tive than  organs  not  inflamed. 


HISTORY  383 

carried  chiefly  by  tlie  va^;s  and  the  greater  splanclmics ;  both  con- 
tain medullated  fibers,  found,  according  to  Edgworth,  in  the  vagus 
at  the  level  of  the  diaphragm.  This  view  is  opposed  to  that  held 
by  Lennander  and  Meyers  (122),  that  the  sensory  fibers  of  the 
vagus  do  not  extend  below  its  recurrent  laryngeal  branch.  Edg- 
worth also  makes  the  observation  that  on  the  warming  of  the 
vagus  its  conductivity  seems  to  increase. 

As  to  the  manner  of  production  and  conduction  of  the  visceral 
pain  impulse  little  is  known,  though  it  is  held  that  the  pain  is: 
(1)  "due  to  induction  of  a  current  in  adjacent  fibers  in  a  manner 
comparable  to  the  electrical  induction  in  two  adjacent  but  uncon- 
nected nerves"  (probably  not  correct)  ;  or  (2)  that  the  "nerve  cen- 
ter, spinal  or  cerebral,  which  receives  the  afferent  impulses  is  so 
unduly  excited  that  in  its  disturbed  condition  it  attributes  the 
afferent  impulses  to  the  wrong  afferent  nerve" ;  or  it  may  be  possi- 
ble (3)  that  "transference  may  take  place  in  the  sensorium." 
Although  the  method  of  the  production  and  conduction  of  the 
impulse  is  in  doubt,  yet  no  doubt  exists  as  to  the  actuality  of  its 
presence.  A  peculiarity  of  its  perception  is  that  it  is  not  felt  in 
the  organ  in  which  it  is  produced,  but  is  referred  or  reflected  to 
the  body  wall,  where  it  becomes  either  the  so-called  somatic  pain, 
or  is  perceived  as  a  form  of  hyperalgesia.^ 

Location  of  Pain. — That  the  pain  of  visceral  disease  is  not 
necessarily  located  directly  in  the  involved  viscera  may  be  seen 
from  the  following: 

(1)  On  movement  of  the  involved  organ  there  is  no  change 
in  the  character  or  location  of  the  pain : 

(a)  Movement  of  the  heart  produces  no  change  in  the  char- 
acter of  the  anginal  pain.  If  the  pain  were  in  the  heart  itself, 
each  contraction  of  the  heart  would  produce  a  change  in  the  char- 
acter of  the  pain. 

(&)  Peristaltic  contraction  of  the  stomach  produces  no  change 
in  the  type  of  the  pain  of  gastric  ulcer ;   also,  changes  in  the  posi- 

^  This  view  has  recently  been  very  strenuously  opposed  by  Hertz,  who 
claims  that  pain  sensation  can  reside  in  the  internal  viscera  themselves 
(Hertz,  106b,  p.  48). 


384  PAIN   IN   ABDOMINAL   VISCERAL   DISEASE 

tion  of  the  stomach  due  to  respiration  produce  no  change  in  the 
location  of  the  pain.  If  the  pain  were  located  in  the  stomach, 
movement  or  change  in  the  position  of  the  organ  would  of  neces- 
sity produce  a  change  in  the  character  or  location  of  the  pain. 

(2)  The  pain  is  not  located  directly  over  the  diseased  area 
in  the  involved  organ ;  indeed,  it  may  not  even  be  over  the  organ 
at  all : 

(a)  Cardiac  anginal  pain  may  be  felt  down  the  arm  or  even 
up  in  the  neck. 

(&)  Pain  of  gastric  ulcer  is  not  directly  over  the  site  of  the 
ulcer,  as  has  been  proved,  time  after  time,  by  operations. 

(3)  The  area  of  hyperesthesia  may  be  distributed  over  a 
much  wider  area  than  that  under  which  the  organ  is  located. 

Transference  of  Pain. — Because  of  the  apparent  non-location 
of  pain  in  the  diseased  viscera  producing  it,  many  attempts  were 
made  to  explain  the  relationship  between  the  area  of  pain  and 
disease  in  the  viscera.  The  most  successful  of  these  was  by  Head, 
who,  in  a  thesis  read  before  the  University  of  Cambridge,  in  June, 
1892,  and  before  the  Neurological  Society  of  London,  November 
10,  1892,  first  opened  the  way  for  the  study  of  peripheral  sensory 
manifestations  of  visceral  lesions.  He  claimed  that  the  manner  of 
transference  of  pain  sensation  is  this:  that  the  stimulus  affects 
the  peripheral  distribution  of  a  nerve  distributed  to  a  viseus,  and 
that  this  stimulus  is  carried  to  the  cord  and  enters  the  sympathetic 
system  through  the  sensory  root  posterior  to  the  ganglion.  In  the 
cord  the  nerve  cells  of  these  fibers  (from  the  sympathetic)  come 
into  intimate  contact  with  the  cells  of  the  fibers  from  the  periph- 
eral sensory  system,  and  incite  them  to  reaction,  so  that  stimuli 
occur,  and  are  transmitted  to  the  brain,  so  that  the  brain  centers 
perceive  them  as  coming  from  the  peripheral  distribution  of  these 
same  somatic  or  body  nerves. 

By  a  reference  to  Figs.  31,  32,  33,  it  may  readily  be  seen  how 
the  stimulus  can  be  reflected  from  one  set  of  neurons  to  another 
set ;  and  it  is  thus  that  the  excessive  irritative  stimulus  arising 
in  the  splanchnic  area  is  interpreted  in  some  distant  area  as  pain. 
Head  has  laid  down  a  law  particularly  applicable  to  this  state, 


TRANSFERENCE    OF    PAIN 


385 


namely,  "that  where  a  painful  stimulus  is  applied  to  a  part  of  low 
sensibility,  in  close  central  connection  with  a  part  of  much  greater 
sensibility,  the  pain  produced  is  felt  in  the  part  of  higher  sensi- 
bility, rather  than  in 
that  of  lower  sensi- 
bility to  which  the 
stimulus  is  actually 
applied." 

Wilamow  ski's 
(109  b)  experiments, 
while  confirm- 
ing Head's  deduc- 
tions, show,  in  some 
cases,  areas  of  re- 
duced sensibility  cor- 
responding in  outline 
to  the  areas  of  in- 
creased sensibility  in 
other  cases.  He  be- 
lieves that  this  hypo- 
algesia  obeys  the 
same  laws  and  is 
subject  to  the  same 
influences  as  the  cor- 
responding hyperal- 
gesia, and  that  both  are  of  the  same  origin. 

In  this  relation  it  was  noticed  by  Mackenzie  that  in  but  very 
few  cases  does  the  hyperesthesia  associated  with  visceral  disease 
occupy  the  entire  area  of  distribution  of  a  particular  nerve,  as 
the  area  of  cutaneous  hyperesthesia  associated  with  cardiac  dis- 
ease does  not  extend  throughout  the  entire  area  of  distribution  of 
the  fourth  dorsal  nerve,  but  is  generally  confined  to  the  skin  on 
the  anterior  surface  of  the  chest.  It  does  not  pass  around  to  the 
posterior  surface ;  also,  it  is  sharply  delimited  at  the  clavicle,  and 
does  not  spread  upward  into  the  area  of  distribution  of  the  fourth 
cervical,  which  lies  above  the  clavicle.     It  may  extend  down  the 


Fig.  82. — Figure  Showing  the  Anterior  Dsi- 

TRIBUTION  OF  THE  NiNTH,  TeNTH,  ELEVENTH 

AND  Twelfth  Dorsal  Nerves. 
The  shaded  parts  indicate  the  areas  in  which 
pain  is  most  frequently  observed  in  abdominal 
visceral  disease. 


386  PAIN   IN   ABDOMINAL   VISCERAL   DISEASE 

inner  side  of  the  arm  and  forearm  into  the  areas  of  distribution 
of  the  second  and  third  dorsal.  Mackenzie  (110b)  claims  that 
these  fields  of  hyperesthesia  are  not  accurately  defined,  that  they 
may  overlap  each  other,  and  that  they  are  not  particularly  limited 
to  any  definitely  defined,  special  area.  These  areas  of  hyper- 
algesia of  Mackenzie  are  most  likely  nothing  but  the  zone  areas  of 
hyperalgesia,  as  described  by  Head,  whose  work  at  that  time  was 
unfamiliar  to  Mackenzie. 

In  some  cases  the  visceral  lesion  may  produce  an  irritable 
focus  in  the  cord,  so  that  stimuli  coming  to  this  place  would  be 
perceived  as  pain,  while  normally  they  would  not  be  so  per- 
ceived, or,  in  some  cases,  would  not  be  felt  at  all.  For  instance, 
the  liver  and  the  stomach  receive  their  nerve  supply  from  the 
same  seginent  of  the  cord.  Liver  disease  may  produce  such  an 
irritation  of  this  segment,  that,  on  the  entrance  of  food  into  the 
stomach,  the  nen^e  impulses  from  the  stomach  to  the  cord,  which 
ordinarily  are  not  painful,  would  then  be  perceived  as  painful. 
Such  examples  we  all  have  seen,  and,  in  many  cases,  they  lead  to 
a  wrong  diagnosis  (Mackenzie), 

Persistence  of  irritability  of  associated  segmental  areas  of  the 
cord  may  explain  the  presence  of  hyperalgesia,  due  to  excitation 
of  these  associated  areas.  Thus,  in  a  case  of  gall-stone  colic  (Mac- 
kenzie), in  which  there  was  jaundice,  there  was  also  extreme  hy- 
peralgesia of  the  skin  of  the  upper  part  of  the  abdomen,  especially 
marked  in  the  epigastrium.  This  persisted  for  some  days  after 
the  stone  had  been  passed  and  had  been  found  in  the  stool.  Dur- 
ing the  time  the  hyperalgesia  persisted  food  taken  into  the  stom- 
ach produced  severe  pain  in  the  epigastrium.  With  the  disap- 
pearance of  the  hyperalgesia  of  the  skin  the  pain  on  taking  food 
ceased.^ 

Mackenzie,  in  continuing,  says  that  "here  there  seems  little 
doubt  that  the  stimulation,  set  up  by  the  ingestion  of  food,  which 
passes  to  the  spinal  cord  normally  unperceived,  reached  that  por- 
tion of  the  cord  which  had  been  abnormally  excited  by  the  gall- 

1  This  association  of  pain  with  the  ingestion  of  food  may  also  be  due 
in  many  cases  to  the  associated  peristalsis  set  up  in  related  organs  by  the 
entrance  of  the  food  into  the  stomach. 


TRANSFERENCE    OF    PAIN  387 

stone  colic,  and  had  hjpersensitized  the  centers  of  the  cutaneous 
nerves  for  j)ain  which  supply  the  epigastric  region." 

Shock,  also,  sometimes  affects  certain  cord  areas,  as  in  per- 
sons who  experience  pain  in  a  certain  area  (hyperalgesia)  when 
startled.  Mackenzie's  explanation  is  that  when  startled  a  stimulus 
passes  down  certain  tracts  in  the  spinal  cord,  affecting  normally 
the  centers  of  the  muscular  nerve  supply,  as  evidenced  by  the 
sudden  contraction  of  nearly  all  the  muscles  in  the  body.  The 
stimulus  is  not  of  sufficient  strength  to  affect  the  sensory  nerve 
centers  in  a  healthy  cord,  unless  there  are  abnormally  irritable 
foci  in  the  cord.  However,  if  such  should  be  present,  the  stimulus 
in  passing  through  them  affects  the  excitable  sensory  nerve  centers, 
and  pain  arises  and  is  referred  to  the  peripheral  distribution  of 
the  nerves  stimulated.  It  may  also  happen  that  pain  is  produced 
by  a  stronger  and  more  powerful  contraction  of  the  excitable  and 
hyperalgesia  muscles. 

Some  mention  should  be  made  of  the  views  of  Hertz,  who  has 
carefully  discussed  this  whole  question  in  his  1911  Goulstonian 
lectures  (''Sensibility  of  the  Alimentary  Canal").  He  points  out 
that  Lennander  and  Mackenzie  did  not  take  into  consideration 
the  fact  that  a  nerve  ending  may  be  sensitive  to  one  form  of  stim- 
ulation and  may  be  insensitive  to  another.  The  one  is  an  ade- 
quate, the  other  an  inadequate  stimulus.  The  eye  does  not  react 
to  sound  stimuli,  nor  the  taste  buds  to  those  of  light.  Thus,  the 
abdominal  viscera,  not  being  exposed  to  touch,  are  probably  not 
stimulated  by  touch  stimuli,  but  that  they  react  to  adequate  stim- 
uli there  is  no  question.  All  that  the  older  observers  showed 
was  that  pinching,  pricking,  cutting  were  not  natural,  adequate 
stimuli.  The  fact  of  the  matter  is  that  the  abdominal  viscera  are 
exquisitely  sensitive  to  deep-pressure  stimuli,  such  as  those  pro- 
duced by  tension.  Thus,  slight  distention  of  the  intestinal  mus- 
cular coat  leads  to  discomfort,  and  marked  stretching  to  severe 
pain. 

The  normal  stimuli  reactions  in  tlie  intestine  are  those  of 
contraction  and  relaxation;  these  two  are  going  on  continuously. 
There  is,  as  Meltzer  has  pointed  out,  a  law  of  contrary  innerva- 


388  PAIN    IN   ABDOMINAL   VISCERAL   DISEASE 

tion,  which  permits  of  this  wave  of  contraction  and  relaxation, 
and  any  interference  with  this  law,  such  as  occurs  in  colic,  in 
obstructions,  etc.,  gives  rise  to  paroxysmal  and  severe  pain. 

The  pains  of  gastric  ulcer  and  duodenal  ulcer  are  to  be  thus 
interpreted.  In  colic  an  abnormally  strong  peristaltic  wave 
occurs  in  one  part  of  the  alimentary  canal,  the  part  immediately 
below  which  should  normally  relax,  following  the  law  of  con- 
trary innervation,  is  unable  to  do  so,  owing  to  organic  disease,  or 
to  spasm;  the  intermediary  segment  is  thus  subjected  to  steadily 
increasing  pressure,  which  soon  produces  pain,  the  distention  be- 
ing the  adequate  stimulus. 

Hertz  believes  that  the  only  cause  of  true  visceral  pain  is  ten- 
sion. Thus,  a  study  of  the  visceral  pains  resolves  itself  into  an 
analysis  of  the  two  forms,  the  tension  pains  and  the  reflex  pains, 
which,  as  has  been  pointed  out,  are  exceedingly  rich  and  varied, 
and  of  great  diagnostic  value  topographically. 

Even  with  the  adequate  stimulus,  however,  the  intestines  are 
much  less  sensitive  than  is  the  skin  to  its  adequate  pain  stimuli. 
The  inaccuracy  of  localization  of  the  tension  pains  is  no  argu- 
ment against  them,  since  the  brain  is  the  perceiving  organ  and 
it  registers  the  general  topography  of  an  organ,  not  its  variations 
in  location,  as,  for  instance,  in  the  movements  of  the  stomach. 
Thus,  there  is  no  valid  reason  why  the  pain  of  a  gastric  ulcer 
should  vary  with  every  movement  of  that  viscus.  With  the  vis- 
cera, however,  which  move  the  least,  the  localization  of  pain  re- 
mains the  most  stable,  other  things  being  equal. 

Should  the  resistance  of  the  patient  be  lowered  from  any 
cause,  such  as  occurs  in  the  anemic  and  weakened  state  which 
follows  upon  a  severe  fever  or  illness  of  any  kind,  it  has  been 
found  that  reflected  and  referred  pains  are  much  more  likely  to 
occur. 

After  the  elicitation  of  referred  or  reflected  pain,  it  is  neces- 
sary to  localize  the  viscus  producing  it.  The  technic  is  the  fol- 
lowing: (1)  delimit  the  area  of  hyperalgesia  as  nearly  as  pos- 
sible, and  orient  it  with  a  cord  segment;  (2)  find  out  what  or- 
gans are  supplied  by  this  segment;  (3)  examine  the  organ  or  or- 


TRANSFERENCE    OF   PAIN  389 

gans  for  disease;  (4)  see  if,  by  manipulation  of  the  organ,  the 
pain  can  be  reproduced. 

The  transmission  of  stimuli  to  the  cord  also  affects  the  mus- 
cular centers  which  lie  adjacent  to  the  sensory  centers  involved. 
These  stimuli  augment  that  which  is  normally  present  in  the 
muscle,  and,  instead  of  the  normal  tonicity,  cause  a  state  of  tonic 
contraction.  This  contraction  may  be  limited  to  a  portion  of  a 
muscle,  may  involve  the  entire  muscle,  or  may  affect  several 
muscles  whose  centers  lie  adjacent  to  each  other.  This  muscular 
center  hypersensibility  also  accounts  for  the  exaggerated  reflexes 
(principally  abdominal)  which  are  so  often  present  in  visceral 
diseases. 

As  irritation  of  the  viscera  causes  pain  to  be  referred  to 
certain  areas,  it  has  been  found  that  stimulation  of  these  areas 
also  is  referred  back  and  causes  reflex  changes  in.  the  viscera. 


CHAPTER    XXI 

DIAGNOSIS  OF  ABDOMINAL  PAINS 

NATURE    OF    VARIOUS    ABDOMINAL    PAINS 

The  lesions  of  the  abdominal  viscera  producing  pain  are  prin- 
cipally those  which  cause  contraction,  active  spasm,  or  excessive 
passive  dilatation  of  the  involuntary  muscle  fiber  in  the  walls  of 
these  viscera.  Inflammation  of  the  viscera  also  causes  pain ;  but 
in  many  cases  ulceration  of  a  hollow  viscus  may  exist  for  years 
without  producing  the  slightest  distress.  This  is  well  exempli- 
fied in  ulcers  of  the  stomach,  gall  bladder  and  appendix  (Moullin 
and  others). 

In  nearly  all  cases  in  which  a  severe  and  long  contraction  of 
a  hollow  organ  is  present,  there  is,  above  the  area  of  contraction, 
an  area  of  dilatation,  so  that,  at  the  junction  of  the  contracting 
segment  wdth  the  dilating  segment,  a  jDlace  is  present  where  trac- 
tion on  the  mesentery  is  severe  and  prolonged.  It  is  likely  that 
this  traction  and  pulling  cause  the  excruciating  pain  of  intestinal 
and  other  hollow  viscera  colics.-^  That  excessive  passive  dilatation 
of  an  abdominal  organ  may  cause  pain,  is  verified  in  many  cases, 
such  as  when  tympany  of  the  stomach  or  colon,  with  severe  pain, 
comes  after  operation.  After  relief  of  the  dilatation  by  the  pas- 
sage of  the  stomach  or  rectal  tube,  the  pain  disappears.  Many 
have  experienced  the  sense  of  discomfort  and  distention  after  the 
ingestion  of  a  hearty  meal,  and  it  is  easy  to  understand  how  this 
disagreeable  sensation,  if  the  distention  of  the  stomach  were  pro- 
longed beyond   tho   limits  of   its  normal  capacity,   might  be  in- 

1  Hertz  claims  that  colic  is  due  to  an  irritation  directly  on  the  sensory 
terminal  fibers  in  the  muscle  layer  of  the  visceral  walls. 


NATURE    OF    VARIOUS    ABDOMINAL    PAINS  391 

creased  to  one  of  actual  pain.  There  are  many  cases,  also,  in 
which,  during  dilatation  of  the  stomach  for  the  purpose  of  record- 
ing its  capacity,  the  patient  complains  of  a  sharp  pain  in  the 
epigastrium.  These  are  but  isolated  examples  of  conditions  which 
are  very  common. 

In  the  spasmodic  contractions  and  the  dilatations  of  hollow 
viscera  the  pain  is  generally  referred  to  the  body  wall,  and  hence 
is  called  somatic.  The  point  of  reference,  in  many  cases,  is  some 
distance  away  from  the  location  of  the  lesion.  Thus,  the  pain 
felt  in  stomach  distention  is  in  the  epigastrium,  immediately  be- 
neath the  ziphoid  cartilage,  at  a  point  that  is  somewhat  remote 
from  the  region  of  the  stomach  as  projected  on  the  abdominal 
wall.  The  logical  way  to  explain  the  apparent  non-association  of 
the  area  in  which  the  pain  is  felt  with  the  organ  in  which  it  is 
produced  is  that  these  remote  regions  are  in  relation  with  one 
another  by  means  of  nerve  connections.  An  explanation  of  this 
seeming  inconsistency  may  be  formed  from  a  study  of  cord  zones, 
as  elucidated  by  Head.  It  is  known  that  the  stomach  is  supplied 
by  the  seventh,  eighth  and  ninth  dorsal  visceral  zones,  and  that  it 
is  especially  related  to  the  seventh  zone.  It  is  also  known  that 
the  maximum  point  of  tenderness  and  sensibility  of  the  seventh 
zone  is  in  the  epigastrium,  immediately  beneath  the  ziphoid. 
Therefore,  in  any  lesion  of  the  stomach  which  may  be  painful, 
the  pain,  as  a  rule,  is  reflected  to  this  point,  or  to  an  analogous 
area  on  the  back  opposite  the  ninth  or  tenth  dorsal  spine.  These 
pains  are  spoken  of  as  reflected  pains,  and  should  more  properly, 
perhaps,  be  considered  under  the  class  of  pains  which  are  felt  at  a 
distance  from  the  lesions  causing  them,  such  as  referred,  reflected, 
transferred  and  associated  or  sympathetic  pains. 

Referred  pain  is  frequent  in  lesions  of  the  nerves  or  of  the 
centers  of  these  nerves,  which  supply  the  integument  of  the  an- 
terior abdominal  wall. 

Under  referred  pains  are  to  be  placed  those  due  to  tabes 
dorsalis,  tuberculosis  of  the  vertebi-ie,  fracture  of  the  verte- 
bra, osteoarthritis  of  the  spine,  insufficiency  'of  the  vertebrae, 
spinal  meningeal  inflammation  or  tumor,  neuritis  of  the  lumbar 


392  DIAGNOSIS    OF   ABDOMINAL    PAINS 

or  dorsal  nerves,  pressure  by  growths,  inflammatory  products,  or 
broken  ribs  upon  the  nerves,  pinching  of  the  nerves  (especially 
of  the  last  two  intercostals)  between  the  adjacent  ribs,  diaphrag- 
matic pleurisy  and  rheumatism  of  the  diaphragm,  and  aneurysm  of 
the  abdominal  aorta.  Acute  mediastino-pericarditis,  from  direct 
extension,  sometimes  causes  pain  to  be  felt  in  the  higher  epigastric 
and  lower  breasjt  region.  For  a  proper  consideration  of  all  these 
pains,  the  reader  is  referred  to  the  section  under  which  referred 
pain  is  considered. 

Reflected  abdominal  pains  are  the  most  common  variety,  and 
probably  number  fifty  per  cent,  of  all  varieties  of  visceral  pain. 
They  are  the  result  of  a  stimulus  applied  either  to  a  sympathetic 
or  to  a  cerebrospinal  nerve.  This  stimulus  is  carried  to  the 
posterior  horns  of  the  cord,  and  actively  stimulates  other  asso- 
ciated sensory  fibers.  The  stimulus  is  then  perceived  as  pain, 
and  the  sensation  is  referred  to  the  peripheral  distribution  of  the 
stimulated  sensory  neurons,  and  thus  it  occurs  that  the  peripheral' 
distribution  of  the  pain  may  be  in  an  altogether  different  region 
from  that  in  which  the  stimulus  originated. 

Transferred  abdominal  pain  is  that  form  of  pain  in  which  the 
impulse  is  transferred,  either  directly  across  the  cord  to  the  other 
side,  or  to  a  higher  or  a  lower  level  in  the  cord,  thus  changing 
the  location  of  its  peripheral  distribution  to  a  higher  or  lower 
level  on  the  body  wall.  This  is  one  of  the  most  annoying  pains 
to  interpret.  It  may  be  found  in  the  opposite  side  of  the  abdomen 
in  appendicitis,  pus  tubes,  diseased  ovaries,  renal  calculus  and 
pelvic  peritonitis.  Pain  transferred  to  a  higher  or  a  lower  level 
than  that  of  the  disease  is  illustrated  by  the  abdominal  pain  in 
pneumonia  (q.  v.),  the  clavicular  pain  in  extrauterine  pregnancy, 
and  the  pains  over  the  fourth  costal  cartilage  (left  side)  in  disease 
of  the  common  duct. 

The  shoulder  pain,  which  may  be  present  in  diseases  of  ab- 
dominal organs,  has  been  considered  by  Peter  to  be  due  to  phrenic 
nerve  irritation,  which  carries  the  stimulus  to  tlie  roots  of  the  cer- 
vical nerves,  from  whence  the  sensation  is  referred  as  pain  to 
their  area  of  distribution  (Mackenzie  and  Peter). 


NATURE    OF   VARIOUS    ABDOMINAL   PAINS  393 

Syinpathetic  pains  are  sometimes  produced  when  the  irrita- 
tion of  a  center  in  the  spinal  cord  is  so  great  that  other  adja- 
cent centers  are  stimulated  and  send  impulses  to  the  brain, 
so  that  pain  is  also  interpreted  as  coming  from  their  distri- 
bution areas.  This  may  happen  in  acute  appendicitis  when 
the  cord  segments  above  and  below  the  segment  connected  with 
the  appendix  are  irritated  and  refer  pain  to  their  area  of  dis- 
tribution. 

By  reference  to  the  diagram  of  pain  paths,  it  may  readily  be 
seen  how  the  various  paths  are  propagated   and  conveyed.      It 

SHOULD  ALWAYS  BE  BOKNE  IN  MIND  THAT  IT  IS  IMMATERIAL  WHAT 
PART  OF  A  NERVE-CIRCUIT  IS  AFFECTED  ;  THE  PAIN  WILL  ALWAYS 
BE  INTERPRETED  AS  COMING  FROM  THE  PERIPHERAL  DISTRIBUTION 
OF   THE  NERVE  FIBERS  WHICH  ARE  INVOLVED. 

Regional  Pains. — For  the  zone  segments  involved  in  disease 
of  the  different  viscera  see  Figures  24,  25,  26.  Each  zone  segment 
has  one  or  more  maximal  points  of  tenderness  which  are 
sensitive  in  any  painful  disease  of  the  viscera  supplied  by  this 
special  segment.  It  should  be  noticed  that  the  term  "painful" 
diseases  of  the  viscera  is  used ;  for,  as  is  known,  every  disease  of 
the  abdominal  viscera  is  not  painful;  and  while  the  majority  of 
the  visceral  diseases  at  some  period  of  their  development  become 
painful,  there  is  a  well-defined  percentage  which  never  do.  The 
peculiarity  of  these  nonpainful  diseases  may  be  accounted  for 
from  the  fact  that,  in  the  evolution  of  the  disease,  the  parietal 
peritoneum  or  the  peritoneal  attachments,  as  the  mesentery,  meso- 
appendix  or  mesocolon,  have  never  been  involved.  We  have 
already  seen  that  Lennander  explained  all  abdominal  pain  as  a 
result  of  pulling,  pressure  or  traction  upon  the  peritoneum.  In 
this  relation,  I  would  like,  by  means  of  an  interpolation,  to  call 
attention  to  the  experiences  of  physicians  of  a  previous  genera- 
tion, who  frequently  groped  in  the  dark  in  a  vain  attemp)t  to  cor- 
relate the  symptoms  and  the  disease  seen  in  their  patients.  A 
case  in  point  is  one  in  which  pain  extended  from  the  midline 
posterior  above  the  hip  to  the  midline  in  front,  in  which  shingles 
were  present.     The  patient,  a  woman",  died  on  the  third  day  of 


394  DIAGNOSIS    OF    ABDOMINAL    PAINS 

the  disease,  and  on  autopsy  an  inflammation  of  the  peritoneum 
and  appendix  was  found.  "During  life  it  was  quite  impossible 
to  form  a  reliable  opinion  as  to  the  nature  of  the  lesion  which 
gave  rise  to  the  pain.  In  view  of  our  later  knowledge,  we  would 
be  able  to  diagnose  the  difiiculty  with  ease*'  (McCall  Anderson, 
8G0).  A  full  discussion  of  these  views  will  be  given  in  a  subse- 
quent chapter. 

One  of  the  first  results  of  abdominal  pain  is  the  crippling  of 
the  respiration.  This  is  noticed  especially  in  men,  who  are  accus- 
tomed to  use  the  diaphragm  in  respiration  much  more  than 
women.  Where  painful  intraabdominal  disease  occurs,  the  dia- 
phragm partakes  of  the  reflex  of  all  other  muscles,  and  becomes 
rigid  and  motionless,  so  as  to  protect  the  diseased  area.  As  a 
consequence,  abdominal  respiration  is  hindered  or  abolished. 

EXAMINATION    FOR   PAIN 

After  this  necessarily  brief  consideration  of  the  pathology  of 
various  abdominal  pains,  it  is  in  order  to  consider  more  closely, 
and  in  a  more  detailed  manner,  the  routine  examination  for  ab- 
dominal pain  and  tenderness.  After  that,  it  may  be  permissible  to 
review  the  various  divisions  of  the  abdomen,  and  the  pains  which 
lie  within  their  borders.  ,In  the  examination  of  the  abdomen  for 
pain,  the  routine  is  as  follows : 

Localization  of  Pain. — The  patient  should  be  recumbent, 
the  shoulders  raised,  knees  flexed,  mouth  open,  and  the  breath- 
ing regular  and  easy.  The  examiner's  hand  should  then  be  laid 
flat  over  the  abdomen,  at  first  with  very  slight  pressure,  to  elicit 
general  tenderness ;  then  the  fingers  should  be  pressed  in  with 
more  force,  in  order  to  elicit  localized  tenderness  at  special  points. 
The  tips  of  the  different  fingers  should  now  be  successively  de- 
pressed, in  order  to  define  more  accurately  the  localization  of  the 
area  of  tenderness.  After  the  location  of  an  area  of  tenderness, 
it  is  well  to  determine  its  extent  by  concentric  palpation.  Con- 
centric palpation  is  made  by  starting  from  the  periphery  and 
gradually  making  pressure  towards  the  point  of  greatest  tender- 


EXAMINATION    FOR    PAIN 


395 


ness.     In  this  way  the  area  of  hypersensitiveness  and  the  point  of 
greatest  pain  are  determined. 

Localization    of   the    Organ    Producing-    Pain. — After  deter- 


Liver 

Gall  bladder 

Pancreas 


Enlarged  liver 


Intestines 

Large 

Small 
Enteritis 
Lead  colic 
Omentum 

Cysts 

Carcinoma 


Floating  kidney 


Appendix 
Ovary 

Fallopian  tube 

Typhoid  fever 

Referred  pain 

Pleurisy 

Pneumonia 


Uterus 


Aneurysm  of 
descending 
aorta 

Stomach 

Spleen 

Pancreas 


Fig.  83.  —  Anterior  View  of  Abdominal 
Zones  with  Corresponding  Organs. 

Midline  pain  maj'-  be  due  to  hernia  of  the 
hnea  alba.  Pain  over  entire  abdominal 
wall  with  tenderness  on  pressure  indicates 
rheumatism  of  the  abdominal  muscles. 
Pain  over  any  part  of  the  abdomen  may 
be  found  to  be  due  to  disease  of  the 
vertebra  (caries,  sarcoma,  etc.). 


Intercostal  neu- 
ralgia 

Referred  pain 
in  pleurisy, 
pneumonia, 
pericarditis, 
appendicitis, 
visceroptosis 


Splenomegaly 


10 

Kidney,  ureter 
Descending   co- 
lon   (pericoli- 
tis) 

11 

Referred  pain 
Girdle  pain  of 
locomotor 
ataxia,  myeli- 
tis,  spinal 
meningitis 
Arteriosclerosis 
of  abdominal 
vessels 


12 

Ruptured  extra- 
uterine preg- 
nancy 

Hernia 


13 

Uterus(midline) 

Ovary  and  Fal- 
lopian tubes 
(laterally) 

Bladder 
Distention 
Tuberculosis 
Calculus 

Ruptured  ex- 
trauterine 
pregnancy 

Hernia 


mining  the  presence  of  pain,  it  is  in  order  to  locate  the  organ  pro- 
ducing it.  For  the  purpose  of  localization,  the  abdomen  is  divided 
into  three  regions:  (1)  the  upper,  (2)  the  middle,  and  (3)  the 
lower.  The  upper,  Avhich  lies  in  the  angle  formed  by  the  costal 
margins  and  a  line  connecting  the  lowest  points  on  the  costal 
arches,  practically  coincides  with  the  epigastric  area,     The  middle 


396 


DIAGNOSIS    OF    ABDOMINAL    PAINS 


area  lies  between  this  zone  and  another  line  connecting  the  two 
iliac  crests.  Below  this,  and  bounded  at  the  base  by  the  iliac 
and  pubic  bones,  is  the  lower  zone.  Each  of  these  areas  is  divided 
by  a  line  extending  from  the  ensiform  cartilage  to  the  pubes  into  a 
right  and  a  left  region,  and  the  middle  zone  is  divided  by  an 


Aneurysm  of  the_  _ 
descending  aorta  "  " 


Liver 
Lungs 
Pleura 


Kidney 

Spine 

Lumbago 


-  Sacroiliac  disease 


Fig.  84. — Posterior  View  of  Abdominal  Zones. 

imaginary  line  passing  down  the  extreme  lateral  aspect  of  the 
body  into  an  anterior  and  a  posterior  zone. 

In  the  annexed  figure  an  attempt  is  made  to  outline  the  organs 
producing  painful  affections  of  each  zone.  •  In  the  upper  zone, 
which  is  included  between  the  diaphragm  and  the  zonal  line  divid- 
ing the  middle  zone  from  the  upper,  two  lateral  zones  are  present 
at  either  side  beneath  the  ribs.  They  are  called  the  hypochon- 
driac zones.  Reference  to  the  figures  will  show  the  organs  giving 
rise  to  pain  in  each  zone. 

Lesions  Causing-  Epigastric  Pain. — In  considering  the  re- 
gional localization  of  abdominal  pain  it  is  well  to  pay  at  least 
partial  attention  to  the  great  variety  of  lesions  to  which  pain  in 
the  epigastrium  may  be  due ;  for,  owing  to  the  presence  in  the  epi- 


EXAMINATION    FOR    PAIN  397 

gastrium  of  the  solar-plexus,  with  its  somatic  peripheral  distribu- 
tion, pain  in  this  region  may  be  symptomatic  of  a  lesion  of  almost 
any  of  the  abdominal  organs.  The  organs  most  frequently  causing 
epigastric  pain  are: 

(1)  The  Stomach. — The  pain  is  very  often  associated  with 
vomiting,  and  generally  bears  some  relationship  to  the  ingestion 
of  food.  It  is  found  in  acute  gastritis,  gastralgia,  hemorrhage, 
ulcer,  perforation,  injury,  carcinoma,  and  obstruction  from  any 
cause. 

(2)  The  Intestines. — The  pain  is  due  to  hemorrhage,  rupture 
from  ulcer  or  injury,  obstruction  accompanied  by  increase  of  peri- 
stalsis, and  the  formation  of  a  tumor. 

(3)  The  Appendix. — In  all  forms  of  acute  appendicitis  pain 
is  present  at  first  in  the  epigastrium,  but  quickly  radiates  to  the 
right  iliac  fossa. 

(4)  The  Liver,  Gall  Bladder  and  Ducts. — In  acute  peri- 
hepatitis breathing  is  painful,  and  localized  tenderness  is  present ; 
biliary  colic  is  often  followed  by  jaundice;  in  cholecystitis  the  en- 
larged gall  bladder  can  be  felt,  and  chills  and  fever  are  generally 
present;  in  rupture  of  the  gall  bladder  or  of  the  ducts  symptoms 
of  peritonitis  rapidly  supervene ;  in  carcinoma  there  are  general 
signs  of  the  disease,  such  as  emaciation,  and  a  positive  hemolytic 
test.  According  to  Riedel,  ninety-seven  per  cent,  of  epigastric 
pains  are  due  to  gall-stones. 

(5)  The  Pancreas. — In  acute  pancreatitis  there  generally  is 
a  history  of  previous  ^all-stone  disease,  with  no  cholecystitis,  and 
no  signs  of  a  gastric  lesion. 

(6)  The  Kidney. — In  renal  colic,  pyonephrosis  and  hydro- 
nephrosis there  are  urinary  findings,  such  as  blood  or  pus  in  the 
urine,  to  indicate  the  disease. 

(7)  The  Spleen. — Splenitis,  or  traumatic  rupture,  may 
cause  epigastric  pain. 

(8)  Ectopic  Pregnancy. — Rupture  of  an  ectopic  preg-nancy 
sometimes  causes  ej^igastric  pain. 

(9)  Locomotor  Ataxia. — Locomotor  ataxia  causes  a  pain 
which  may  be  referred  to  the  epigastrium.     There  are  also  present 


398  DIAGNOSIS    OF    ABDOMINAL    PAINS 

other  signs  of  the  disease,  such  as  Romberg  incoordination  and 
Argyll-Robertson  pupil. 

(10)  Pneumonia. — In  pneumonia  there  are  signs  of  lung 
consolidation. 

(11)  Pelvic  Lesions. — Embolism  of  either  the  superior  or 
the  inferior  mesenteric  artery  may  be  present,  and  produce  epi- 
gastric pain  with  all  the  symptoms  of  bowel  obstruction,  but  of 
much  greater  severity;  in  these  cases  some  other  grave  disease, 
from  which  the  clot  obstructing  the  vessel  is  derived,  is  also 
present. 

(12)  Adhesions  between  any  of  the  organs  underlying  the 
seat  of  pain  may  also  be  the  cause  of  pain. 

Character  of  the  Epigastric  Pain. — If  the  pain  in  the  epigas- 
trium is  sudden  and  severe,  and  does  not  follow  a  straining  effort, 
examination  should  be  made  for: 

(1)  Appendicitis,  which,  if  present,  finally  causes  the  pain 
to  become  localized  in  the  appendix  area.  Typhoid  fever,  which 
in  some  cases,  when  it  is  of  sudden  onset,  commences  as  a  severe 
abdominal  pain,  and  has  often  been  mistaken  for  appendicitis. 

(2)  Cholecystitis,  in  which  the  pain  finally  becomes  -local- 
ized to  the  right  hypochondrium. 

(3)  Acute  hemorrhagic  pancreatitis,  in  which  the  pain  re- 
mains in  the  epigastrium. 

(4)  Perforating  ulcer,  in  which  the  pain  remains  where  it 
first  appeared  for  but  a  very  short  time,  and  soon,  because  of  the 
development  of  peritonitis,  becomes  generalized ;  or,  in  some  cases, 
owing  to  extension  of  the  exudate  may  at  first  be  most  severely 
felt  in  the  pelvis. 

(5)  In  obstructed  intestines  the  pain,  as  a  rule,  has  a  ten- 
dency to  ascend  toward  the  ensiform,  until  tympany  becomes  ex- 
cessive, when  it  is  felt  over  the  entire  abdomen. 

(6)  In  perforated  gall-bladder  the  pain  remains  in  the 
region  of  the  gall-bladder,  or  passes  down  to  the  appendiceal 
region,  until  generalized  peritonitis  develops,  when  the  pain  be- 
comes diffused  over  the  entire  abdomen. 

Sudden  abdominal  pain,  following  a  straining  effort  and  not 


EXAMINATION    FOR    PAIN  399 

confined  to  the  epigastrium,  may  be  due  to:  (a)  hernial  strangu- 
lation; (&)  ruptured  extrauterine  pregnancy;  (c)  ruptured  ap- 
pendix; (d)  tearing  of  peritoneal  adhesions;  (e)  rupture  of 
a  cystic  tumor;  (/)  twisting  of  an  ovarian  tumor  or  cyst  on  its 
pedicle. 

As  they  will  not  be  extensively  considered  elsewhere,  a  little 
time  will  be  devoted  here  to  cysts  in  which  the  pain  is  of  sudden 
onset,  very  severe,  and  paroxysmal,  sometimes  continuous.  The 
cause  of  the  pain  is  torsion  of  the  pedicle  (ovarian  cyst  or  tumor). 
This  causes  an  extravasation  of  blood  into  the  tumor  substance 
and  a  consequent  rise  of  internal  cystic  or  tumor  pressure  with 
tension  and  traction  on  the  capsule.  Such  an  increase  is  espe- 
cially apt  to  occur  when  the  return  circulation  through  the  veins 
is  obstructed.  Should  the  capsule  be  lax,  and  the  capacity  of  the 
tumor  great,  the  pain  from  extravasation  may  not  be  great,  even 
though  symptoms  of  hemorrhage  may  supervene.  Should  the  tor- 
sion occur  in  the  pedicle  of  a  wandering  spleen  or  of  a  prolapsed 
kidney,  the  pain  may  be  due  to  a  beginning  necrosis  of  the  tissue, 
although  it  Avould  seem  more  logical  to  define  the  increased  in- 
tracapsular tension  as  being  the  active  and  potent  cause.  Pain, 
while  of  the  greatest  use  in  the  diagnosis  of  twisted  pedicle,  is  not 
of  paramount  importan-ce.  Richardson  says  that  ''a  history  of 
tumor,  a  sudden  enlargement  and  tenderness  in  that  tumor,  pre- 
ceded or  accompanied  by  pain,  are  sufficient  to  make  the  diagnosis 
of  twisted  pedicle." 

If  the  abdominal  pain  is  due  to  irritation  of  the  sympathetic 
fibers,  it  is  present  at  first,  as  a  rule,  in  the  central  part  of  the 
abdomen  and  later  becomes  localized  more  definitely  to  the  area 
associated  with  the  diseased  organ  or  organs.  On  the  contrary, 
if  the  cerebrospinal  nerves  are  involved,  from  the  development 
of  a  peritonitis,  the  pain  is  localized  directly  over  the  affected  vis- 
cera. Bed  clothing  cannot  be  tolerated,  and  the  abdominal  mus- 
cles are  rigid.  The  rigidity  of  the  abdominal  muscles  over  the 
diseased  area  is  the  result  of  somatic  muscular  reflex  contraction. 
Hyperesthesia  of  the  skin  over  the  affected  viscera  is  also  present. 
This  sensitiveness  is  generally  not  so  sharply  delimited  as  is  the 


400  DIAGNOSIS    OF    ABDOMINAL   PAINS 

reflex  tenderness  from  visceral  disease.  It  is  most  severe  at  the 
site  of  the  most  severe  inflammatory  reaction,  and  diminishes 
concentrically  from  this  point. 

Sudden  abdominal  pain  is  diffuse,  or  is  localized  in  the  umbili- 
cal region  (where  the  solar-plexus,  the  so-called  abdominal  brain, 
the  sensorium  of  the  abdominal  viscera,  is  located).  This  pain 
may  be  associated  with  shock  and  collapse,  which,  when  present, 
are  fairly  certain  indicators  of  a  severe  abdominal  lesion.  In 
the  condition  of  shock  the  associated  symptoms  of  importance  are 
a  rapid  pulse,  obliteration  of  the  liver  dullness  (look  for  rupture 
of  a  viscus),  and  rigidity  of  the  abdominal  musculature.^ 

Should  the  pain  result  from  rapid  and  extensive  extravasations 
of  septic  material,  it  is  sharp,  sudden  and  overwhelming.  It  is 
often  ushered  in  by  a  feeling  as  though  something  had  given 
way.  At  first  it  is  continuous,  violent,  and  almost  unbearable; 
later  it  becomes  paroxysmal  and  intermittent,  or  is  dull  and  con- 
tinuous. The  pain,  which  at  first  is  localized  sharply  in  the 
region  of  the  extravasation,  becomes  generalized  as  the  septic  ma- 
terial spreads  throughout  the  abdominal  cavity.  When  the  i>eri- 
tonitis  becomes  diffused  and  the  bowel  distention  is  excessive,  pain 
usually  subsides,  and  when  it  does  so,  it  is  a  sign  of  grave  signifi- 
cance (Richardson). 

Pain  Due  to  Functional  Processes. — When  abdominal  pain 
occurs,  inquiry  should  be  made  concerning  the  following  points: 

(1)      The  relationship,  if  any,  to  the  ingestion  of  food.     If 

'Lennander  explains  the  diffuse  abdominal  pain  present  in  the  early 
stages  of  so  many  infectious  processes  in  the  abdominal  cavity  as  being  due  to: 

(1)  An  increased  sensitiveness  of  a  large  portion  of  the  parietal  perito- 
neum, owing  to  lymphangitis  or  peritonitis. 

(2)  A  considerable  increase  and  irregularity  of  peristaltic  action,  which, 
in  addition  to  pain,  often  produces  a  feeling  of  sickness  and  vomiting,  and 
leads  to  one  or  more  actions  of  the  bowels  at  the  commencement  of  these  ill- 
nesses. 

(3)  On  account  of  increased  sensitiveness,  the  movements  of  the  stomach 
and  intestines  against  the  parietal  peritoneum,  and  the  stretching  of  their  re- 
spective mesenteries,  are  felt  as  severe  pains. 

(4)  In  most  cases,  however,  the  general  peritoneal  irritation  soon  passes 
away;  only  the  part  more  especially  infected  remains  in  a  condition  of  inflam- 
mation, and  the  abdominal  pain  becomes  localized  at  this  spot. 


EXAMINATION   FOR    PAIN  401 

there  is  any  such  relationship  examine  (a)  the  stomach  and  in- 
testine for  a  gastric  or  duodenal  ulcer,  or  for  adhesions,  or  the 
intestine  for  a  volvulus  or  obstruction,  in  which  case  the  pain,  at 
first,  is  periodic  and  paroxysmal,  and,  later,  continuous  and  of 
an  aching,  dragging  character.  If  the  pain  is  sudden  and  intense, 
especially  if  it  commences  in  the  umbilical  region  and  gradually 
becomes  localized  to  the  right  side,  examine  for  appendicitis.  If 
the  pain  is  continuous  and  increasing,  it  indicates  that  the  local 
peritonitis  is  spreading.  This  is  especially  the  case  should  there 
be  a  synchronous  increase  in  the  tenderness,  (b)  In  pancreatic 
disease  it  may  indicate  a  rupture  of  the  duct  or  an  acute  hemor- 
rhage and  inflammation,  (c)  Biliary  disease,  as  a  rule,  causes  a 
pain  which  comes  on  about  the  first  or  third  hour  after  eating, 
at  the  time  of  the  gTeatest  intestinal  activity,  and  is  especially 
marked  when  percystic  adhesions  are  present. 

(2)  Relationship  of  pain  to  defecation  indicates:  (a)  hem- 
orrhoids, which  generally  are  associated  with  bleeding;  (b)  fis- 
sures of  the  anus,  which  often  are  associated  with  itching;  (c) 
carcinoma  of  the  rectum,  in  which  bleeding  is  very  marked  and 
sometimes  is  present  previous  to  the  onset  of  pain;  (d)  ulcera- 
tions of  the  rectum,  which,  as  a  rule,  are  not  painful,  unless  the 
sphincter  region  is  involved. 

(3)  If  the  pain  occurs  in  conjunction  with  menstruation, 
the  genital  organs  should  be  examined,  the  uterus,  tubes  and 
ovaries  all  being  subjected  to  a  close  inspection.  If  they  are 
affected,  the  pain,  because  of  the  congestion  then  present,  becomes 
worse  during  the  menstrual  period.  Sudden  abdominal  pain  is 
often  premonitory  of  a  miscarriage. 

Pain  Due  to  Intestinal  Diseases. — A  few  facts  worthy  of 
attention  are:  That  increased  peristalsis  of  the  bowel  may,  in 
case  of  obstruction,  be  a  potent  cause  of  abdominal  pain.  This 
pain  is  located  across  the  middle  of  the  abdomen ;  never  below  the 
umbilicus  in  obstruction  of  the  small  intestine,  but  generally  above 
in  lesions  of  the  large  intestine  (Mackenzie).  In  obstruction  of 
the  large  intestine  painful  states  arise.  These  are  the  result  of 
the  obstruction  to  the  forward  peristalsis,  and  are  called  colics. 


402  DIAGNOSIS    OF   ABDOMINAL    PAINS 

Of  intestinal  colics,  there  are  those  due  to  acute  indigestion, 
in  which  the  pain  is  usually  accompanied  by  vomiting;  those 
due  to  poisoning  as  by  lead  or  brass.  (These  metals  irritate  and 
cause  constriction  of  the  blood  vessels  in  the  intestinal  walls,  thus 
indirectly  irritating  the  sympathetic  nerve  filaments  and  causing 
muscular  contraction  and  colic.  Pal  claims  that  in  lead  fcolic  the 
blood  pressure  is  increased  from  one-half  to  twice  the  normal,  and 
that  this  increased  pressure  irritates  the  terminal  filaments  of  the 
sympathetic,  and  thus  causes  pain)  ;  those  due  to  hernia,  which 
are  generally  accompanied  by  vomiting;  those  due  to  uremia,  which 
may  precede  other  uremic  symptoms  by  a  considerable  interval 
(Musser)  ;  those  due  to  gall-stones,  which  are  probably  the  most 
frequent  cause  of  colic  (here  the  pain,  as  a  rule,  is  located  in  the 
right  ejDigastric  zone,  but  may  be  felt  in  the  right  lumbar  zone 
anterior)  ;  and  lastly,  those  due  to  renal  calculus,  which  are  very 
severe,  and  sometimes  are  mistaken  for  intestinal  obstruction, 
chiefly  because  of  the  intestinal  distention  and  inability  to  move 
the  bowels,  a  condition  often  the  result  of  large  doses  of  morphia 
which  ■  the  patient  has  been  given. 

In  children  painful  paroxysms  frequently  occur  in  the  course 
of  purpura.  This  disease,  according  to  Guinon,  is  due  to  a  toxic 
infective  agent,  with  special  action  on  the  nervous  system ;  so  that 
it  seems  very  probable  that  the  colicky  pains  are  due  to  intestinal 
cramps,  the  result  of  a  deranged  peristalsis,  which  in  turn  is  the 
result  of  malactivity  of  the  nervous  system.  The  ordinary  colics 
of  children  are  accompanied  by  a  great  restlessness,  throwing 
about  of  the  body,  and  interrupted  cries.  Relief  comes  on  the 
expulsion  of  flatus  (Kerr,  861). 

Perforation  in  typhoid  is  a  cause  of  very  severe  and  acute 
abdominal  pain.  In  Manges'  series  of  nineteen  cases  of  typhoid 
perforation,  abdominal  pain  was  the  first  symptom  to  appear  in 
fourteen.  In  two  of  them,  however,  it  was  accompanied  by  a 
chill,  and  in  two  others  by  vomiting.  Though  not  the  initial 
symptom,  it  was  present  in  seventeen  of  the  nineteen  cases.  One 
of  the  best  descriptions  of  the  pain  due  to  typhoid  perforation  is 
that  given  by  Selby.     What  he  says  applies  to  perforation  of  any 


EXAMINATION    FOR    PAIN  403 

hollow  abdominal  viscus.  He  says  that  abdominal  pain  is  a  most 
constant  and  reliable  indication  of  perforation,  depending,  to  be 
sure,  on  the  mental  condition  of  the  patient  and  his  appreciation  of 
the  sensation.  The  pain  varies  in  degree,  character  and  location. 
It  may  be  so  severe  as  to  force  a  cry  from  a  comatose  patient,  and, 
on  the  other  hand,  so  mild  as  to  attract  but  slight  or  no  attention 
from  a  conscious  patient.  It  may  begin  as  a  sudden,  sharp,  stab- 
bing and  agonizing  sensation,  or  may  come  on  gradually.  Its 
duration  varies  also.  It  is  usually  circumscribed  and  is  lo- 
cated in  the  lower  part  of  the  abdomen  near  to  the  median  line, 
or  towards  the  right  side,  and,  generally  speaking,  the  more  cir- 
cumscribed it  is,  the  more  keenly  it  is  appreciated.  Occasionally 
it  is  referred  to  the  umbilicus  and  other  parts  of  the  abdomen, 
and  even  to  the  penis.  If  it  be  general  at  the  start,  as  it  some- 
times is,  it  may,  in  the  course  of  a  short  time,  become  confined 
to  the  lower  part  of  the  abdomen.  On  the  contrary,  if  primarily 
it  is  localized,  and  later  becomes  generalized,  it  strongly  suggests 
progressive  peritoneal  infection.  The  value  of  pain,  however,  as 
a  symptom,  lies  not  so  much  in  its  limits,  its  severity,  the  manner 
of  its  appearance,  and  its  persistence,  as  in  the  fact  that  it  itself 
is  present.  Its  modifying  features,  when  present,  may  be  weighed 
in  proportion  to  their  degree,  but  when  absent  may  be  ignored  in 
arriving  at  a  diagnosis. 

In  one  case  of  typhoidal  perforation  there  was  sudden  pain 
in  the  lower  abdomen,  causing  the  patient  to  cry  aloud ;  soon  after- 
ward there  was  intense  pain  in  the  penis  (Allaben).  The  rela- 
tion of  this  penis  pain  to  the  perforation  is  difficult  to  determine. 

Abdominal  pain  may  be  caused  by  adhesions,  for  a  discussion 
of  which,  see  under  Peritonitis. 

Abdominal  Tenderness. — Tenderness  on  pressure,  being  close- 
ly allied  to  pain,  may  be  considered  in  the  light  of  a  less-marked 
manifestation  of  that  sensation.  It  usually  accompanies  pain, 
and  not  infrequently  is  present  when  actual  pain  is  absent.  It  is 
found  within  the  same  areas  as  is  the  associated  pain,  but  is  con- 
fined within  more  narrow  limits.  Thus,  diffuse  pain  is  occa- 
sionally  associated   with    a    localized    tenderness.      This    feature 


404 


DIAGNOSIS    OF   ABDOMINAL   PAINS 


renders  tenderness  of  value  in  the  determination  of  the  approxi- 
mate location  of  the  lesion.  However,  as  such,  it  is  not  without 
fallacy.  A  widening  of  the  tender  area  may  be  taken  as  an  indi- 
cation of  a  spreading-  peritonitis,  and,  as  such,  is  an  indicator,  of 
greater  reliability  than  an  increasing  diffusion  of  the  pain.  "The 
value  of  tenderness  as  a  symptom  is  enhanced,  needless  to  say, 
by  its  characterizing  features,  but,  as  is  true  of  pain,  its  real 
value  lies  in  its  mere  presence." 


Pericholecystitis 


F'eriappendicitis 
Spreading     pel- 
vic peritonitis 


Perisalpingitis 
Pelvic  peritonitis 


Extension  of  the 

tenderness 
Morris's  points 
McBurney'spoint 

Pressure  over 
this  area  will 
cause  pain  if 
the  ureter  is 
inflamed 


Fig.  85. — Areas  of  Local  Tenderness,  when  the  Inflammation  of  the 
Appendix,  Gall  Bladder,  and  Fallopian  Tube  and  Ovary  Has 
Spread  to  ihe  Peritoneum  and  Has  Produced  a  Localized  Peri- 
tonitis. 

Morris's  points  are  also  shown,  as  well  as  the  area  in  which  pressure  is  made 
best  over  an  inflamed  ureter. 

When  abdominal  pain  is  present,  tenderness  should  always 
be  sought  over  the  areas  associated  with  the  gall-bladder,  the 
pylorus,  the  appendix,  and  the  hernial  openings.  Abdominal 
tenderness  is  sometimes  due  to  a  hypersensitiveness  of  the  abdom- 
inal musculature,  such  as  is  produced  by  prolonged  coughing. 
This  tenderness  is  generally  in  the  epigastrium  in  the  region  of 
the  recti  muscles. 

Percussion  is  of  value  in  determining  abdominal  tenderness. 
It  often  happens  that,  in  percussing  the  abdomen,  attention  is 
drawn  to  a   particular  region  by  the  wincing   and   involuntary 


EXAMINATION   TOR    PAIN  405 

shrinking  of  the  patient  from  the  percussing  finger.  This  always 
indicates  tenderness.  After  the  attention  is  drawn  to  a  particular 
area  of  the  abdomen,  more  refined  means  of  defining  the  degree 
and  extent  of  tenderness  (palpation  and  pin-prick  pressure)  may 
be  used.     Such  measures  have  been  described  in  earlier  chapters. 

Types  of  Tenderness. — Tenderness  is  of  two  types :  tempo- 
rary and  permanent.  Tenderness  which  is  present  temporarily 
over  an  organ  may  be  due  to  the  distention  of  the  organs  (stom- 
ach or  intestines)  with  air  or  gas.  As  soon  as  the  distention  is 
relieved  pain  and  tenderness  cease.  Chronic  tenderness  is  more 
likely  to  be  caused  by  inflammatory  changes,  especially  in  those  in 
whom  the  abdominal  wall  or  the  parietal  peritoneum  is  involved. 
Should  the  tenderness  be  superficial,  and  so  acute  that  even  the 
lightest  pressure  causes  pain,  it  is  probable  that  the  condition 
is  one  of  superficial  neuralgia,  such  as  is  common  during  infec- 
tious diseases.  On  the  other  hand,  deep  tenderness  is  only  of 
relative  value,  since  even  in  many  normal  cases  the  forcing  of 
the  hand  deep  into  the  abdomen  will  cause  pain. 

Reflected  Tenderness.— Tn  the  consideration  of  tenderness  the 
fact  must  not  be  lost  sight  of  that  tenderness  is  not  always  present 
over  the  organ  causing  it ;  for  in  many  cases  pressure  on  or  over 
the  inflamed  or  diseased  organ  will  cause  pain  at  some  distant 
area,  and  pressure  over  this  area  is  painful,  even  though  it  is  at 
a  distance  from  and  has  no  direct  connection  with  the  organs 
causing  the  pain.  This  is  a  most  important  point  in  the  diagnosis 
of  disease,  and  should  never  be  forgotten. 

A  point  of  tenderness  in  cases  of  pelvic  adhesions  is  given  by 
Cumston,  who  says  that  "a  symmetrical  point  of  tenderness  on 
the  opposite  side  of  the  abdomen  from  McBurney's  point  will  be 
found  in  pelvic  adhesions." 

This  point  of  tenderness,  as  given  by  Cumston,  closely 
approximates  the  point  of  tenderness  defined  by  Morris  as  being 
present  in  pelvic  lesions.  Morris  gives  his  point  as  being  one  and 
one-half  inches  from  the  navel  on  a  line  running  from  the  navel 
to  the  umbilicus.  He  claims  that  when  this  point  is  tender  on 
the  right  side  alone,  appendicitis  is  present,  and  that  when  it  is 


406  DIAGNOSIS    OF   ABDOMINAL   PAINS 

tender  on  both  sides,  pelvic  disease  is  present.  This  view  has 
been  controverted  by  Hubbard,  who  ascribes  to  these  areas  of 
tenderness,  even  in  cases  of  chronic  appendicitis,  only  secondary 
importance.  McBurney's  point,  which  is  also  a  point  of  tender- 
ness in  appendicitis,  is  situated  in  the  lower  left  quadrant  of  the 
right  lumbar  zone  anteriorly,  on  a  line  drawn  from  the  umbilicus 
to  the  anterior-superior  sj)ine  of  the  ilium,  and  one  and  one-half 
inches  from  the  anterior-superior  spine.  It  has  not  the  signifi- 
cance formerly  ascribed  to  it  (see  Appendix). 


POSTURE    IN    ABDOMINAL   DIAGNOSIS 

The  posture  of  the  patient,  in  cases  of  severe  abdominal  dis- 
ease, is  characteristic.  The  patient  assumes  two  general  positions: 
in  the  first,  the  posture  of  abdominal  protection,  the  patient  is 
alert,  and  while  with  one  hand  he  attempts  to  ward  off  any  ab- 


> 


W^.. 


Fig.  86. — Posture  of  Abdominal  Protection  Present  in  Peritonitio. 

In  cholecystitis  and  appendicitis,  the  hands  maj^  be  the  reverse  of  what 
they  are  in  the  figure :  the  right  hand  acts  as  guard  and  the  left  as  pro- 
tector. In  salpingitis,  the  protecting  hand  is  over  the  lower  abdomen. 

dominal  interference  (touch,  palpation),  with  the  other  hand  he 
covers  (without  making  pressure)  the  painful  area.  In  the  second 
form  the  j^atient,  instead  of  warding  off  abdominal  pressure, 
seems  to  find  relief  when  pressure  is  applied  to  the  abdomen.  He 
is,  as  a  rule,  doubled  up,  with  the  limbs  flexed  on  the  abdomen, 


POSTURE   IN   ABDOMINAL   DIAGNOSIS 


407 


Fig.  87. — Position  in  Abdominal  Colic,  A.ssumed  on  Lying. 

and  the  belly  muscles  tightly  contracted.  In  some  cases  the  pa- 
tients make  pressure  on  the  abdomen  with  the  hands,  while  in 
other  cases  they  use  for  this  purpose  some  other  object  (pillowSj 
bolsters).  In  the  first  posi- 
tion inflammation  of  some 
of  the  abdominal  organs  is 
indicated,  and  if  the  sensi- 
tiveness is  markedly  in- 
creased peritonitis  probably 
has  already  set  in.  The  sec- 
ond position  indicates  some 
variety  of  colic,  the  parox- 
ysms of  which  are  indicated 
by  the  exaggeration  of  the 
position  which  the  patient 
assumes  when  the  pain 
comes  on.  The  patient,  as 
a  rule,  lies  down,  or,  if  this 
is  impossible,,  assumes  a  sit- 
ting posture,  with  the  arms 
folded  and  the  body  bent,  so 

that  pressure  is  made  on  the 
1  1  Fig.  88. — Position  in  Abdominal  Colic, 

Assumed  on  Sitting. 


408  DIAGNOSIS    OF   ABDOMINAL   PAINS 

FORMS   OF   ABDOMINAL   PAIN 

To  complete  this  chapter  a  brief  discnssion  of  some  of  the 
most  common  forms  of  abdominal  pain  is  necessary.  Among 
those  most  frequently  encountered  is  renal  colic,  the  pain  of 
which  is  generally  on  the  affected  side,  passes  downward  toward 
the  pelvis,  and  is  often  very  acutely  felt  in  the  testicle  on  the 
side  of  the  disease.  In  the  purpura  of  infants  painful  abdominal 
paroxysms  are  common  (455).  According  to  Musser,  abdominal 
pain  is  often  a  precursor  of  uremia.  This  pain  is  usually  situated 
in  the  right  or  left  hypochondrium,  and,  when  in  the  left  hypo- 
chondrium,  has  been  mistaken  both  for  gastritis  and  gastric  per- 
foration. Enteroptosis,  particularly  gastroptosis,  may  produce 
pain  in  the  suprapubic  region  (Deaver). 

Keen  reports  a  case  of  rupture  of  the  rectus  muscle,  in  which, 
at  the  time  of  the  rupture,  sudden,  sharp  pain  was  felt  in  the 
abdominal  wall.  Such  a  rupture  may  occur  in  a  typhoid  patient 
who  is  convalescing,  and  generally  follows  some  sudden  exertion. 
The  symptoms  of  rupture  are  sudden,  sharp  pain  and  tenderness 
localized  to  the  point  of  rupture.  The  rupture  is  generally  accom- 
panied by  vomiting.  Examination  shows  a  depression  in  the 
course  of  the  muscular  fibers,  later  accompanied  by  ecchymosis  and 
swelling. 

If  the  pain  is  in  the  rectum,  it  may  be  caused  by  a  pro- 
lapsed colon. 

Arteriosclerosis  of  the  abdominal  vessels  also  causes  abdomi- 
nal pain,  which  generally  is  severe  and  paroxysmal.  For  a  full 
discussion,  see  under  Arteriosclerosis  of  the  Mesenteric  Arteries. 

A  condition  is  described  by  Depage  in  which  pain  is  due  to  a 
displacement  of  a  rib.  Examination  will  show  that  the  eleventh 
and  in  some  cases  the  tenth  rib  is  projecting  over  the  iliac  crest. 
The  pain  is  intermittent  and  is  worse  when  the  patient  walks  or 
moves  about.  Pressure  over  the  ends  of  the  tenth  and  eleventh 
ribs  is  painful,  and  pain  is  also  experienced  if  the  angles  of  the 
ribs  are  brought  one  over  the  other.  The  condition  is  most  fre- 
quent on  the  right  side. 


rORMS    OF   ABDOMINAL   PAIN  409 

A  rather  rare  and  frequently  overlooked  cause  of  abdominal 
pain  is  anemia  (Musser,  5). 

Functional  Pains. — Richardson  speaks  of  neuralgia  of  the  ab- 
dominal organs  as  a  cause  of  abdominal  pain.  This  term,  as  a 
rule,  is  a  misnomer,  for  nearly  all  cases  of  supposed  abdominal 
neuralgia  are  due  to  some  condition  having  a  more  definite  patho- 
logic basis  than  is  found  in  neuralgia.  The  only  reason  that  these 
lesions  are  not  properly  diagnosed  is  that  the  search  for  their  path- 
ology has  not  been  sufficiently  prolonged  nor  assiduously  enough 
pursued.  While  neuralgia  may  and  does  occur  as  a  cause  of  ab- 
dominal pain,  it  is  much  less  frequent  than  is  supposed. 

The  so-called  functional  pains  are  frequently  classified  as  neu- 
ralgic, but  in  nearly  all  cases  these  pains  can,  by  patient  search, 
be  shown  to  be  due  to  organic  lesions,  sometimes  obscure,  but 
present  nevertheless.  Under  functional  pains,  Richardson  gives 
gastralgia,  nephralgia,  oophoralgia,  and  simple  intestinal  colic 
from  gas.  All  except  the  last  are  recognized  entities,  but  not 
in  the  same  manner  as  is  generally  understood. 

Gastralgia  is  only  a  term,  usually  applied  to  a  painful  state 
of  the  stomach,  having  an  unknown  basic  cause.  In  some  cases, 
when  it  is  due  to  a  painful  condition  of  the  muscular  structure, 
it  should  be  called  gastromyalgia ;  on  the  other  hand,  if  the  nerves 
are  affected,  it  should  be  termed  gastroneuralgia.  However,  all 
painful  conditions  of  the  stomach,  whatever  the  etiology,  may  be 
classed  under  the  generic  term  gastralgia.  So  likewise  painful 
states  of  the  kidney  and  ovary  may  be  called  nephralgia  and  oophor- 
algia. But  often,  alas,  when  we  suffix  "algia"  to  the  name  of  an 
organ,  it  means  that  we  are  but  adding  a  cloak  to  conceal  our 
ignorance  of  the  real  cause  of  the  pain  which  is  present ;  it  means 
that  we  are  naming  the  diseased  state  from  a  symptom  instead  of 
from  the  pathology.  The  careless  use  of  these  terms  cannot  be 
too  strongly  condemned,  and  they  would  be  seldom  employed  if 
it  were  borne  in  mind  that  they  frequently  are  but  the  indicators 
of  ignorance  and  sloth. 

The  presence  of  abdominal  pain  in  neurasthenics  should 
always  be  a  subject  of  considerable  investigation  before  a  defi- 


410  DIAGNOSIS    OF   ABDOMINAL   PAINS 

nite  diagnosis  is  made.  The  neurasthenic  is  frequently  subject 
to  the  delusion  that  there  is  sometliing  radically  wrong  in  the 
abdomen,  and  even  though  operation  and  removal  of  an  ovary  or 
of  an  appendix  may  relieve  the  symptoms  for  a  time,  the  pain 
soon  returns,  and  is  found  in  a  new  location,  so  that  it  is  almost 
an  impossibility  to  relieve  this  class  of  people,  either  with  or  with- 
out operation.  Psychotherapy  in  the  form  of  reeducation  ia 
probably  at  the  present  time  the  most  efficient  means  at  our  com- 
mand of  producing  relief. 

After  the  review  of  pain,  as  given  in  the  previous  pages,  it 
may  be  well  to  consider  the  time  of  life  at  which  the  different 
pains  are  most  frequent.  For  this  purpose,  life  may  be  divided 
into  four  periods :  infancy,  childhood,  adult  life  and  old  age.  In- 
fancy, with  its  sensitive  and  helpless  condition,  offers  a  double 
hardship  to  the  examiner,  for  he  not  only  has  to  elicit  symptoms, 
but  has  to  derive  them  without  the  patient's  help.  For  this  rea- 
son, pain,  as  a  symptom  of  disease  in  infancy,  is  a  factor  of 
almost  negligible  value.  It  becomes  important  only  as  the  infant 
grows  older,  and,  by  intelligent  cooperation,  is  able  to  tell  the 
examiner  something  of  the  type  and  character  of  the  pain  which 
he  experiences.  Yet,  with  all  these  drawbacks,  even  in  infancy 
pain  is  of  some  little  value.  When  the  infant  continuously  cries 
and  cannot  be  hushed  by  its  mother,  as  a  rule,  it  is  suffering  from 
some  form  of  pain.  The  most  common  causes  of  pain  in  infancy 
are  colic,  gastroenteritis,  and  intussusception.  In  children  one 
should  look  for  these  conditions,  and,  in  addition,  spinal  caries, 
gall-bladder  disease,  appendicitis  and  pneumonia.  In  adult  life 
all  of  the  above,  with  the  addition  of  gall-stones,  gastroduodenal 
ulcer,  pancreatic  disease,  hernia  strangulation,  and,  if  the  patient 
is  a  woman,  ovarian,  tubal  or  uterine  disease  may  be  present.  As 
old  age  comes  on,  the  tendency  to  malignant  growths  increases,  and 
in  case  of  persistent  pain  one  should  seek  for  cancers. 

Care  in  Diagnosis. — As  previously  mentioned,  tabes  dorsalis, 
caries  of  the  vertebric  and  tumors  of  the  spinal  cord  cause  pain. 
These  three  conditions  should  always  be  thought  of  in  those  cases  in 
which  an  abdominal  pain  is  present  without  sufficient  and  definite 


FORMS    OF    ABDOMINAL    PAIN  411 

cause.  So  often  are  they  mistaken  for  disease  of  the  intraab- 
dominal organs  that  the  physician  must  be  very  careful  to  exclude 
them  before  he  arrives  at  any  definite  conclusion.  Howell  (111b) 
speaks  of  cases  of  tabes  dorsalis  being  mistaken  for  cases  of  appen- 
dicitis and  operated  upon.  Lead  poisoning  should  also  be  sought, 
and  when  the  patient  with  colic  is  a  painter,  the  gums  should  be 
inspected  at  once,  to  ascertain  if  the  blue  line  at  the  edge  is  present 
(Burton's  blue  line).  In  lead  colic,  the  abdominal  cutaneous 
hyperalgesia  is  absent  (Robinson,  265). 

Intercostal  neuralgia  causes  pain  which  is  referred  to  the  an- 
terior abdominal  wall,  and  is  likely  to  be  mistaken  for  an  intra- 
abdominal lesion.  The  presence  of  the  pain  points  is  a  differen- 
tiating symptom  (see  Neuralgia). 

Pneumonia  frequently  refers  its  symptoms  to  the  abdomen, 
and  in  some  cases  so  strongly  that  an  abdominal  lesion  has  been 
diagnosed.  In  many  cases  appendicitis  operations  have  been 
performed  ivith  negative  results  for  appendicitis,  and  the  oper- 
ator, to  his  chagrin,  has  found  pneumonia  symptoms  developing 
during  the  course  of  the  next  few  days.  All  cases  of  acute  ab- 
dominal pain,  with  rapid  pulse,  rapid  respiration,  and  high 
fever,  should  at  once  direct  the  attention  to  the  chest.  The  ten- 
derness, also,  is  characteristic,  in  that  in  pneumonia  the  skin 
over  the  abdominal  area  in  which  pain  is  complained  of  is  very 
tender,  but  deep  pressure  is  well  borne  (Howell,  Hood,  Bennett). 
This  is  the  opposite  to  the  rule  in  severe  abdominal  diseases. 

Pleurisy  has  also  been  mistaken  for  abdominal  disease,  and  a 
case  is  cited  by  Bennett  (144,  p.  1005),  in  which  operation  would 
have  been  performed  for  appendicitis  had  it  not  been  that  a  band 
of  tenderness  extending  around  the  abdomen  above  the  umbilicus 
drew  attention  to  the  pleural  involvement. 

Hilton  claims  that  the  abdominal  pains  of  thoracic  visceral 
disease  are  due  to  involvement  of  the  parietal  nerves,  and  a  subse- 
quent reference  of  the  irritation  to  their  distribution  area.  He 
says  that  the  pleura  is  supplied  by  the  intercostal  nerves,  an  opin- 
ion which  is  disputed  by  Mackenzie.     (See  pleura.) 

Abdominal  pain  may  also  occur  with  obstinate  constipation. 


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CONDITIONS  ASSOCIATED  WITH  ABDOMINAL  PAIN     413 

When  it  does  so  occur,  it  may  come  on  rather  suddenly.  It  gradu- 
ally increases  with  little  or  no* increase  in  the  temperature;  finally 
vomiting  of  stercoraceous  material  occurs  and  the  diagnosis  is 
made  clear. 

CONDITIONS  ASSOCIATED  WITH   ABDOMINAL  PAIN 

Spasm  and  Rigidity  of  Muscles. — Spasm  of  the  abdominal 
muscles  nearly  always  accompanies  abdominal  pain,  especially  if 
the  pain  is  severe.  This  symptom  is  lacking  in  those  who  have 
very  lax  or  atrophied  abdominal  walls,  and  it  is  also  much  less 
marked  in  women  than  in  men,  because  their  muscular  develop- 
ment is  generally  much  less  than  that  of  men.  On  the  other  hand, 
severe  rigidity  of  the  abdominal  wall  may,  in  those  of  a  very 
muscular  build,  supervene  upon  a  very  slight  intraabdominal  irri- 
tation. Localized  rigidity  is  a  good  indicator  of  the  region  of  the 
abdomen  involved,  for  the  contraction  generally  takes  place  im- 
mediately over  the  diseased  viscus.  Should  abdominal  rigidity 
gradually  become  lessened,  while  the  toxic  state  of  the  patient 
gradually  increases,  it  indicates  that  the  lesion,  whatever  its 
nature,  is  increasing  in  virulence,  and  is  becoming  dangerous  to 
the  patient.  This  is  particularly  so  if  the  leukocytosis,  which  has 
been  present,  decreases  to,  or  even  below,  the  normal  level.  Spasm 
of  the  abdominal  muscles  is  of  diagnostic  value  in  differentiating 
abdominal  from  pelvic  lesions,  it  being  marked  in  abdominal 
lesions,  and  almost,  if  not  entirely,  absent  in  pelvic  lesions. 

Visceromuscular  Reflex. — In  abdominal  lesions,  also,  the  so- 
called  visceromuscular  reflex  (Mackenzie)  may  be  present  and 
render  the  diagnosis  more  difficult,  especially  since,  in  the  abdomi- 
nal parietes,  the  muscles  have  the  power  of  segmental  contraction 
over  an  area  of  inflammation  or  irritation.  These  segmental 
masses  of  muscles  are  very  deceiving  to  the  palj^ating  hand,  and 
have  been  mistaken  by  the  examiner  for:  (1)  enlarged  ovaries, 
(2)  an  enlarged  and  inflamed  appendix,  (3)  tumors,  intraab- 
dominal and  parietal,  (4)  inflammatory  exudates,  and  (5)  intes- 
tinal tumors,  due  to  volvulus,  intussusception,  etc. 


414  DIAGNOSIS    OF   ABDOMINAL   PAINS 

During  every  abdominal  examination,  the  possibility  of  con- 
fusing these  reflex  muscular  contractions  with  tumors,  etc.,  should 
always  be  borne  in  mind,  and,  since  the  rectus  abdominis  is  mostly 
at  fault,  its  nodal  points  should  be  carefully  mapped  out.  One  of 
these  points  occurs  at  the  umbilicus  and  another  between  the  um- 
bilicus and  the  costal  arch.  Any  swelling  due  to  contraction  of  the 
rectus  would  occur  between  these  points  and  would  be  somewhat 
oblong  in  shape. 

In  the  diagnosis  between  these  phantom  and  true  abdominal 
tumors  it  is  well  to  observe:  (1)  that  a  tumor  may  vary  in  its 
relative  position  to  a  fixed  point  (umbilicus)  on  the  abdominal 
wall,  but  a  contracted  part  of  the  rectus  muscles  does  not  so  vary ; 
and  (2)  that  while  the  tumor,  which  is  the  result  of  contraction 
of  the  muscle,  may  be  so  persistent  and  constant  that  sometimes, 
even  under  chloroform,  it  yields  with  difficulty,  yet  it  always 
does  yield;  while  a  tumor  which  is  the  result  of  organic  disease 
is  more  clearly  defined  when,  as  a  result  of  the  anesthetic  action 
of  chloroform,  relaxation  of  the  rectus  muscle  occurs. 

Toxemia  also  has  a  restrictive  action  on  pain  perception,  and 
if  it  is  pronounced,  abdominal  pain  is  perceived  very  slightly,  or 
not  at  all.  As  Musser  remarks,  when  a  hyperleukocytosis  is 
present,  with  associated  severe  toxic  symptoms,  even  though  pain 
is  absent,  a  serious  lesion  should  be  considered. 

Indicanuria,  as  an  accompaniment  of  pain,  is  of  considerable 
value  in  localizing  the  lesion  to  the  small  bowel. 

Polyuria. — Many  painful  conditions  of  the  abdomen  are  asso- 
ciated with  polyuria,  and  Osier  has  remarked  on  the  frequency  of 
polyuria  in  the  later  stages  of  typhoid  fever. 

Relationship  of  Hysterical  to  Abdominal  Pain. — Hysteria  as  a 
cause  of  abdominal  pain  is  only  mentioned  to  be  condemned.  It 
seems  to  be  a  term  with  which  many  clinicians  hide  their  ignor- 
ance and  diagnostic  distress.  The  more  a  physician  sees  of  ab- 
dominal pain,  and  the  more  frequently  he  follows  his  case  to 
operation  or  to  autopsy,  the  less  seldom  he  makes  a  diagnosis  of 
hysteria.  It  seems  that  nearly  all  so-called  abdominal  pains  of 
hysteric  origin  have  for  their  basis  something  more  than  a  disor- 


CONDITIONS  ASSOCIATED  WITH  ABDOMINAL  PAIN     415 

dered  nervous  system.  Under  the  shadow  of  this  name  are  hid- 
den many  cases  of  gall-stones,  appendicitis  and  gastric  ulcer. 
Many  are  the  patients  who  go  on  to  chronic  invalidism  or  lie  in 
too  early  graves  because  of  the  ignorance  or  inattention  of  their 
physicians  to  these  facts. 

Abdominal  incisions  are  frequent  causes  of  abdominal  pain. 
Since  this  is  of  vital  importance  to  the  surgeon,  I  quote  from 
Maylard,  who,  to  avoid  pain  as  a  result  of  abdominal  incisions, 
recommends  that  the  ''incision  be  made  in  the  most  favorable 
part  of  the  abdomen ;  that  is,  the  part  that  has  the  fewest  nerves, 
and  that,  during  the  operation,  as  little  irritation  or  destruction 
as  possible  to  the  tissues  of  the  wound  be  made." 

Post-operative  abdominal  pain,  according  to  Maylard,  is  caused 
by  irritation  of  the  nerve  endings.  If  it  follows  immediately 
after  operation,  it  is  due  either  to  tight  suturing  or  to  the  pres- 
sure exerted  by  encircling  ligatures.  Tension  is  generally  indi- 
cated by  a  throbbing  pain  or  ache.  When  the  pain  is  due  to  tight 
suturing  or  to  the  ligatures,  it  follows  almost  immediately  upon 
the  operation,  and  generally  is  of  a  stinging,  stabbing  character. 
In  some  cases  a  nerve  may  be  transfixed  with  a  suture  or  ligature, 
and  be  a  constant  source  of  pain  production.  If  the  pain  follows 
twenty-four  to  forty-eight  hours  after  operation,  it  is  due  to  in- 
flammation, with  consequent  swelling  and  pressure.  When  the 
inflammation  is  mild,  little  or  no  pain  results ;  but  should  it  be  so 
extensive  that  exudation  is  present,  the  pressure  from  the  exudate 
upon  the  terminal  nerve  filaments  is  productive  of  pain,  in  some 
cases  very  severe.  The  distress  which  at  first  was  intermittent  is 
now  continuous,  and  should  a  rise  of  temperature  occur  suppuration 
will  generally  be  found  to  be  present.  Inflammation  of  the  skin 
or  subcutaneous  tissues  generally  produces  pain  in  the  first  twenty- 
four  to  forty-eight  hours,  while  inflammation  of  the  deeper  struc- 
tures does  not  produce  discomfort  for  longer  periods.  In  case 
the  inflammation  is  of  the  peritoneum  or  subperitoneal  tissues, 
discomfort  and  pain  do  not  make  their  appearance  until  about 
the  eighth  day  after  operation.  If  the  patient  is  very  obese,  a  con- 
siderable amount  of  effusion  takes  place  into  the  wound,  and,  as 


416  DIAGNOSIS    OF   ABDOMINAL   PAINS 

Maylard  remarks,  unless  drainage  is  provided,  tension,  inflamma- 
tion, and  consequent  pain  will  follow. 

Pain  Referred  to  Extraabdominal  Regions. — In  disease  of 
abdominal  organs  the  pain  is  sometimes  referred  to  an  extraabdom- 
inal location.  For  instance,  it  is  common  to  have  pain  in  the  shoul- 
der in  diseases  of  certain  abdominal  viscera.  This  pain  has  been 
described  as  due  to  irritation  of  the  phrenic  nerves,  which  convey 
the  stimulus  to  the  roots  of  the  cervical  nerves,  to  whose  cu- 
taneous distribution  the  pain  seems  to  be  referred.  This  pain, 
along  with  an  area  of  hyperesthesia  of  the  skin  of  the  shoulder  in 
lung  inflammation,  has  been  attributed  to  diaphragmatic  irritation 
by  Mackenzie,  although  he  also  suggests  that  it  may  be  due  to  the 
vagus  terminations  being  involved.  It  is  probable  that  the  shoul- 
der pain,  which  is  found  associated  with  gall-stone  and  gall-blad- 
der disease,  is  due  to  involvement  of  the  diaphragm  in  the  in- 
flammatory process.  Likewise,  in  certain  cases  of  rupture  of 
extrauterine  pregnancy,  Ave  find  that  pain  is  present  in  this  area. 
In  these  cases  the  pain  may  be  due  to  pressure  upon  the  diaphragm 
by  the  accumulation  of  extravasated  blood  (for  it  is  a  peculiar 
fact  that,  on  standing,  the  pain  often  disapj)ears). 

Absence  of  Pain. — Should  abdominal  pain  be  absent  when  nat- 
urally it  should  be  expected,  or  if  it  should  disappear  before  the 
natural  termination  of  the  disease  would  warrant  its  cessation, 
the  patient  should  be  examined  for:  (1)  perforation  of  the  viscus 
involved,  (2)  gangrene  of  the  diseased  organ,  and  (3)  increase  of 
toxemia  to  such  an  extent  that  the  jiatient's  faculties  are  dulled 
so  that  he  is  unable  to  perceive  pain. 

When  perforation  of  a  viscus  occurs,  pain  is  temporarily  re- 
lieved ;  but  the  relief  is  due  only  to  the  incapability  of  percej)tion 
which  accompanies  the  shock  produced  by  this  condition.  When 
perforation  takes  place  the  pulse  generally  increases  in  rapidity 
and  becomes  weak  and  thready.  The  temperature  first  falls  and 
then  rises,  as  infection  and  a  generalized  peritonitis  ensue.  Any 
localized  tenderness  which  may  have  been  present  before  the 
perforation  now  becomes  diffused,  and  muscular  rigidity,  which 
before  was  restricted  to  one  area,  now  becomes  general.     Should 


CONDITIONS  ASSOCIATED  WITH  ABDOMINAL  PAIN     417 

gangrene  of  aii  abdominal  viscus  occur,  the  temperature,  because  of 
consequent  toxemia,  may  fall.  That  this  fall  is  not  beneficent,  may 
be  seen  from  the  j)ulse,  which  is  constantly  increasing  in  rapidity, 
and  from  the  increasing  stupor  and  somnolence  of  the  patient, 
whose  aj)pearance  indicates  that  he  is  suffering  from  a  most  severe 
disorder.  The  disappearance  of  the  pain  as  an  indicator  of  im- 
provement is  of  value  only  if  all  associated  symptoms  improve  con- 
comitantly with  it.  In  many,  though  not  all  cases,  the  rapid  dis- 
apj)earance  of  the  cutaneous  hyperalgesia  occurs  simultaneously 
with  the  onset  of  gangrene  (Bennett,  142,  p.  1005).  Toxemia  can 
be  easily  diagnosed  by  the  increasing  stuj)or  and  coma  associated 
with  it.  However,  even  in  the  most  advanced  stages  of  stupor  and 
coma,  while  the  patient  does  not  complain  or  cry  out  from  pain, 
a  close  examination  will  disclose  the  facial  expression  of  the  most 
severe  distress. 


CHAPTER  XXII 

PAINS    OF    THE    ALIMENTARY    TRACT 

Lips. — It  is  very  rare  for  the  lips  to  be  afflicted  with  pain 
without  noticeable  organic  change,  although  sometimes  neuralgia 
of  either  the  second  or  third  branch  of  the  fifth  nerve  seems  to 
be  particularly  confined  to  either  the  upper  or  the  lower  lip.  In 
this  case  we  find  that  the  lips  are  normal  in  appearance  but  ex- 
ceedingly tender  to  pressure.  The  pain  also  comes  in  paroxysms, 
between  which  there  is  no  pain  and  absolutely  no  tenderness. 
The  principal  organic  changes  in  the  lips  producing  pain  are  in- 
flammation and  fissure.  Inflammation  of  the  lips  is  generally 
due  to  infection,  which  has  entered  either  through  an  abrasion  or 
a  pustule.  When  it  is  present  there  is  considerable  swelling,  and 
the  pain  is  of  a  constant,  throbbing  character.  The  involved  area 
is  very  tender  to  the  touch,  and  motion  is  almost  if  not  entirely 
abolished,  so  that  it  is  very  difficult  to  take  food.  When  fissures 
are  present  linear  abrasions  may  be  seen  running  across  the  mu- 
cous membrane  of  the  lip,  and  at  the  angles  of  the  mouth,  where 
they  are  very  common.  Opening  the  mouth  is  very  painful,  and 
the  contact  of  the  denuded  surface  with  salty  or  acid  substances 
is  also  very  disagTeeable,  so  that  the  patient  is  averse  to  eating. 

Herpes  of  the  lips  is  very  common  in  the  early  stages  of  in- 
fectious diseases,  and,  as  a  rule,  the  vesicles  are  exquisitely  ten- 
der.    Herpes  of  the  lips  is  frequently  complicated  by  infection. 

Cheeks. — Pain  in  the  cheeks  may  be  due  to  inflammation  or 
to  neuralgia.  Inflammation  is  generally  not  of  local  origin,  but 
is  the  result  of  an  extension  from  adjacent  areas,  such  as  the 
gums,  or  alveolar  processes.  When  it  is  present  the  cheeks  are 
kept  at  rest.  They  feel  as  though  they  were  stiffened,  and  are 
418 


TEETH  4iy 

hard  and  board-like.  There  are  also  considerable  swelling  and 
a  glossy  appearance  of  the  skin.  Neuralgia  (trigeminal)  here  is 
not  different  from  neuralgia  in  other  locations,  and  gives  rise  to 
the  same  signs  and  symptoms.  A  condition  of  the  cheeks  that  is 
very  painful  is  a  vesicular  formation  on  the  internal  mucous  mem- 
brane surface.  This  is  very  disagTceable  and,  though  it  does  not 
cause  any  subjective  pain,  the  least  irritation,  such  as  the  rubbing 
against  it  of  the  tongue,  or  of  solid  or  liquid  food,  causes  a  very 
disagreeable  sensation.  These  vesicles  are  either  the  result  of  nerve 
involvement,  such  as  is  found  in  trigeminal  herpes,  or  are  but  the 
reflex  herpetic  eruptions  of  digestive  disturbances.  If  on  the 
tongue  an  ulcer  that  is  free  or  almost  free  from  pain  is  found, 
syphilis  or  tuberculosis  should  be  sought.  In  mild  inflammations, 
such  as  those  w^hich  accompany  stomatitis,  there  is  moderate  pain, 
which  is  increased  on  the  ingestion  of  food.  At  the  same  time 
there  are  thick,  sticky  saliva,  impaired  taste,  and  often  a  slight  rise 
of  temperature. 

Teeth. — Sometimes,  in  cases  of  toothache,  the  aching  may  be 
due  to  hyperesthesia,  a  common  accompaniment  of  pregnancy. 
Ordinary  toothache  is  due  to  an  irritation  of  one  of  the  branches 
of  the  trigeminus  by  products  of  dental  caries.  At  first  the  pain  is 
more  or  less  localized  to  the  point  of  origin,  but  it  gradually  may 
become  so  accentuated  that  a  general  neuralgia  results,  and  the 
entire  side  of  the  face  may  become  affected.  This  may  increase 
until  the  entire  side  of  the  head  and  neck  is  tender  and  painful. 
This  extension  can  be  explained  by  the  rich  collateral  association  of 
the  trigeminus  with  the  cervical  nerves.  Because  of  this  close  rela- 
tionship it  is  easy  to  understand  how  an  excessive  stimulation  of 
one  nerve  can  produce  reactions  in  adjacent  nerves.  In  some 
cases,  after  the  extraction  of  teeth,  pain  may  persist  for  several 
days,  especially  if  gum-boils  are  present  before  the  extraction,  in 
which  case  the  pain  may  persist  for  five  or  six  days  (Vosper, 
896). 

The  most  sensitive  part  of  a  tooth  is  the  pulp  and  the  agents 
causing  the  greatest  reaction  are  heat  and  cold.  Head  claims 
that,  until  the  pulp  is  involved,  the  pain  remains  local,  but  as 


420 


PAINS    OF    THE   ALIMENTARY    TRACT 


soon  as  it  is  affected  the  local  is  changed  into  referred  pain. 
Thus,  in  the  course  of  destruction  of  a  tooth  three  different  vari- 
eties of  jiain  are  encountered: 

(1)  The  local,  sharp  pain,  associated  with  destruction  of  the 
enamel  and  involvement  of  the  dentine.  It  is  easily  produced 
by  the  sensitive  dentine  coming  into  contact  with  very  hot  or  cold 
substances,  drinks,  etc. 

(2)  The  referred  pain  from  involvement  of  the  pulp  cavity. 
It  seems  that  each  tooth  has  a  separate  area  of  pain  reference; 
for  instance: 


Tooth 

Kefeeence  Area 

Upper  Jaw 

(1) 

Incisors 

Frontonasal  region 

(2) 

Canine 

Nasolabial  region 

(3) 

First  bicuspid 

Nasolabial  region 

(4) 

Second  bicuspid 

Temporal  or  maxillary 

(5) 

First  molar 

Maxillary  region 

(6) 

Second  molar 

Mandibular  region 

(7) 

Third  molar 
Lower  Jaw 

Mandibular  region 

(8) 

Incisors 

Mental 

(9) 

Canine 

Mental 

(10) 

Bicuspid 

Mental 

(11) 

Second  bicuspid 

Hyoid  or  mental 

Hyoid — also  in  ear  and  just  be- 

(12) 

First  molars 

hind  angle  of  the  jaw.     The 

(13) 

Second  molars 

tip  of  the  tongue  on  the  same 
side  is  also  tender. 

(14) 

Lower  wisdom 

Superior  laryngeal  area 

(3)  After  the  pulp  is  destroyed  the  referred  pains  cease  and 
there  are  only  local  pains,  due  to  involvement  of  the  periodontal 
structures.  For  more  detailed  information,  see  Head,  Brain, 
1904,  pp.  406-415. 

Central   trigeminus   pain    (tic    douloureux),   either  from   in- 


TONGUE  421 

volvement  of  the  ganglion  itself  or  its  internal  roots,  or  as  a  re- 
sult of  pressure  (cerebello-pontine  angle  tumor,  neuroma),  often 
leads  to  a  faulty  diagnosis  of  teeth  pains.  Many  patients  suffer  the 
loss  of  one  tooth  after  another  in  the  vain  search  for  the  aifected 
one.  After  the  sacrifice  of  the  teeth  the  dentist  or  physician 
wakes  up  to  the  fact  that  the  disorder  is  central,  and  that  a  grave 
mistake  has  been  made. 

Tongue. — The  lesions  of  the  tongue  which  are  apt  to  give 
rise  to  pain  are  inflammation,  fissures,  ulcers,  new  growths,  and 
vesicles.  Inflammation  can  generally  be  traced  to  some  abrasion 
or  injury,  or  to  an  extension  of  inflammation  from  some  adja- 
cent area ;  however,  tliere  is  a  unilateral  inflammation  (hemiglos- 
sitis)  which  is  probably  of  neurotic  origin.  Fissures  in  the 
tongue,  as  in  all  sensitive  mucous  membranes,  are  apt  to  be  very 
painful,  because  of  the  exj)osure  of  the  sensory  terminal  filaments. 
This  is  also  true  of  ulcers,  which  in  this  location  likewise  are 
very  painful.  New  growths  in  the  tongue  give  rise  to  a  sensation 
of  discomfort  rather  than  to  one  of  pain.  Vesicles  due  to  her- 
petic disturbances  may  appear  on  the  tongue,  and  when  they  do, 
they  cause  great  distress  owing  to  their  extreme  sensitiveness. 
They  generally  are  an  indication  of  a  central  lesion,  central  herpes, 
though  they  may  be,  as  are  similar  vesicles  on  the  cheek,  but 
a  manifestation  of  disturbed  digestion  (reflex  herpes).  When 
due  to  herj)es  the  vesicles  generally  appear  on  the  posterior  half 
of  the  tongue,  which  derives  its  sensory  supply  from  the  glosso- 
pharyngeal nerve.  Tuberculosis  and  syphilis  of  the  tongue  are 
not  painful  unless  there  is  a  breaking  down  of  the  lingual  tissues, 
with  a  consequent  exposure  of  the  sensory  nerve  filaments. 

In  many  cases  a  hyperalgesia  of  the  tongue  is  an  indication  of 
hysteria,  which,  when  present,  generally  gives  rise  also  to  para- 
gusia  or  gustatory  paresthesia  (disturbances  of  the  sense  of 
taste),  the  patient  complaining  either  of  the  disagi-eeable  taste 
of  that  which  would  otherwise  be  agi-eeable,  or  of  the  persistence 
of  a  bitter  or  of  a  sweet  taste  in  the  mouth  when  nothing  has 
been  tasted.  This  is  a  fairly  frequent  condition  in  neurotics, 
particularly  those  suffering  from  neurasthenia. 


422  PAINS    OF    THE   ALIMENTARY   TRACT 

The  presence  of  small,  painful  lesions  of  the  tongue  may  be 
the  first  indication  of  a  nocturnal  epileptic  attack. 

There  is  an  extremely  painful  condition  of  the  tongue,  due  to 
a  papillitis,  in  which  nothing  abnormal  can  be  found  on  the  sur- 
face; but,  on  magnification,  small,  ulcerating  points  are  seen 
hidden  in  the  folds  of  the  mucosa  about  the  fungiform  papillae 
of  the  tip  and  the  margin  of  the  tongue. 

Moeller's  glossitis,  or  chronic  superficial  glossitis,  is  charac- 
terized by  bright  red  lines  or  patches  at  the  margin  or  tip.     The 
pain,  which  is  the  principal  lesion,  is  out  of  all  proportion  to  the, 
local  involvement,  and  is  much  increased  in  chewing  and  speak- 
ing. 

According  to  Riesman  (113b),  pain  in  the  tongue  (glosso- 
dynia)  which  arises  without  any  apparent  organic  lesion,  may  be 
divided  into  the  following,  which  is  the  classification  of  Chaveau 
(112b). 

(1)  Glossodynia  secondary  to  trigeminal  neuralgia,  especially 
the  inferior  dental  branch  of  the  trigeminal. 

(2)  Glossodynia  of  the  insane,  starting  as  a  local  paresthesia. 

(3)  Glossodynia  of  tabes,  corresponding  to  crisis  in  other 
organs. 

(4)  Glossodynia  of  hysteria. 

(5)  Rheumatism  of  the  lingual  muscles,  or  rheumatic  glosso- 
dynia. 

(6)  Glossodynia  due  to  local  causes.  These  may  be  classified 
into  the  extrinsic  and  intrinsic.  The  extrinsic  causes  are:  (a) 
dental  affections  and  artificial  teeth,  and  (h)  granular  pharyngitis 
and  hypertrophy  of  the  posterior  pillars  and  of  the  lingual  tonsil. 
Among  the  intrinsic  causes  are:  (ft)  lingual  varices;  (&)  chronic 
glossitis  from  tobacco,  alcohol,  spices,  iodin,  lead  or  gout,  and  (c) 
papillary  hypertrophy  of  the  follicular  region  of  the  tongue. 

Reference  Areas  in  Diseases  of  the  Tongue. — Disease  of  the 
anterior  portion  causes  pain  to  be  referred  to  the  mental  area ; 
of  the  lateral  portion,  to  the  hyoid  area ;  of  the  dorsum,  to  the 
superior  laryngeal  and  the  occipital  area  (Head). 

Salivary  Glands. — The  salivary  glands  are  subject  to  the  ordi- 


PHARYNX   AND    TONSILS  423 

nary  glandular  pain-producing  diseases,  as  inflammation,  etc. 
There  may  be  present  also,  in  the  ducts  of  the  glands,  some  ob- 
struction which  gives  rise  to  an  intermittent  colic  with  an  asso- 
ciated swelling  and  tumefaction  of  the  gland.  This  condition 
may  sometimes  be  diagnosed  by  running  the  finger  along  the 
course  of  the  ducts,  when  an  obstruction,  if  present,  generally 
may  be  felt.  The  most  common  form  of  obstruction  is  a  salivary 
calculus  (Ranulus).  The  parotid  gland  sometimes  becomes  in- 
flamed, and  is  very  painful,  giving  rise  to  the  entity  called 
"mumps."  It  also  becomes  tender  after  oophorectomy,  and  in  some 
cases  where  orchitis  is  present.  Pain  beneath  the  angle  of  the  jaws, 
in  those  who  are  convalescent  from  typhoid,  should  always  lead 
to  investigation  of  the  parotid  as  the  possible  cause  of  the  pain. 

Phaxynx  and  Tonsils. — Pain  in  the  pharynx  may  be  present, 
either  objectively,  on  swallowing,  or  subjectively,  without  any 
provocative '  act.  In  the  first  case  we  find  that  the  causative 
factors  are  slight,  such  as  small  ulcers  and  superficial  inflamma- 
tions; but  when  the  infectious  agents  extend  deeper,  and  the 
surrounding  connective  tissues  are  involved,  the  pain  is  felt  with- 
out any  exciting  productive  factor,  and  is  continuous.  This  is 
well  exemplified  in  parenchymatous  tonsillitis,  in  which  the  pain 
extends  to  the  angles  of  the  jaws,  also  to  the  ears,  even  down  the 
neck,  and  in  phlegmonous  pharyngitis,  which  is  extremely  pain- 
ful, there  being  a  constant  burning  or  aching  pain,  which  in  some 
cases  assumes  a  throbbing  character.  In  the  latter,  the  pain  may 
be  of  such  magnitude  that  the  patient  lives  a  miserable  existence, 
being  unable  to  eat  or  to  sleep  until  the  abscess  which  has  formed 
ruptures  and  relieves  the  pressure. 

The  tonsils  and  posterior  pharyngeal  wall  may  be  extremely 
tender  in  certain  forms  of  streptococcic  sore  throat,  and  the  pain 
often  persists  for  a  long  period  after  the  cessation  of  the  acute 
inflammation, 

A  so-called  gouty  throat  causes  a  similar  painful  condition  of 
the  pharynx  and  tonsils.  There  are  few  signs  of  inflammation ; 
the  mucous  membrane,  however,  is  lax  and  edematous. 

Various  types  of  pharyngitis,  gra:iular,  follicular,  etc.,  cause 


424  PAINS    OF    THE   ALIMENTARY    TRACT 

pain.  The  diagnosis  depends  upon  a  special  knowledge  of  the 
various  pictures.  All  of  these  conditions  cause  a  certain  amount 
of  referred  pain.  The  pain  in  front  of  the  ear,  complained  of  so 
much  by  patients  with  tonsillar  aifections,  or  by  those  who  have 
some  tonsillar  traumatism,  operative  or  otherwise,  is  in  the  hyoid 
reference  area  of  Head  (for  which,  see  Fig.  GO,  p.  291).  The 
pain  may  also  be  referred  to  an  area  in  the  neck  in  the  submaxil- 
lary triangle.     Palpation  here  will  disclose  an  enlarged  gland. 

Esophagus. — The  esophagus  below  the  cricoid  cartilage  was 
formerly  considered  to  be  non-responsive  to  tactile  and  other  stim- 
uli, but  now  it  is  known  to  be  sensitive  to  heat,  cold,  tactile  and 
chemical  stimuli,  and  it  is  also  held  that  many  apparent  stomach 
sensibilities  are,  in  reality,  esophageal  sensibilities.  Inflamma- 
tion of  the  esophagus  is,  if  severe,  productive  of  considerable 
pain.  The  pain  is  of  a  deep,  burning  character,  and  is  felt 
along  the  course  of  the  esophagus.  Pain  is  also  felt  on  move- 
ment of  the  esophagus,  which  occurs  when  the  head  is  bent  for- 
ward or  backward,  and  is  also  present  when  external  pressure  is 
made  through  the  overlying  tissues  upon  the  esophagus.  Pain  on 
swallowing  is  very  severe.  In  the  severest  cases  of  corrosive 
esophagitis  there  may  be  no  pain. 

Pain  felt  in  the  esophagus,  without  any  objective  lesion,  may 
be  due  either  to  a  hyperesthesia  or  a  paresthesia.  In  the  former, 
pain  is  produced  by  factors  which  cause  irritation,  such  as  in- 
flammation of  the  esophagus,  or  a  neuritis  of  the  nerves  supplying 
it.  The  latter  (neuritis)  gives  rise  to  a  perversion  of  sensation; 
for  instance,  the  act  of  swallowing,  which  ordinarily  gives  rise 
to  no  sensation,  is,  in  this  condition,  interpreted  as  painful.  In 
stenosis  of  the  esophagus  pain,  as  a  rule,  is  absent.  In  cancer  of 
the  esophagus  there  may  be  only  a  feeling  of  distress  or  of  dis- 
comfort under  the  sternum,  generally  localized  to  the  area  of  the 
growth.  Sometimes  severe  pains,  confined  to  the  area  of  the 
growth,  or  referred  to  the  region  of  the  xiphoid  cartilage,  may 
also  be  present.  They  generally  are  of  a  '^tearing,  piercing  char- 
acter, and  radiate  widely  to  the  back,  neck,  or  shoulders."  They 
accompany  the  deglutition  of  food,  but  may  be  independent  of  it, 


ESOPHAGUS  425 

and  are  often  nocturnal.  Thongli  generally  present  only  late  in 
the  disease  tliej  may  be  the  earliest  manifestations  of  it 
(McCrae). 

Referred  pains  may  be  present  in  the  intercostal  spaces  be- 
tween the  shoulder  blades,  in  the  epigastrium,  in  the  throat  and 
head,  in  the  ear,  or  in  the  extremities  (Rosenheim). 

Dyspnea  and  attacks  of  pain  resembling  angina  pectoris  also 
occur.  These  are  duo  to  pressure  on  the  trachea  or  upon  both  re- 
current laryngeal  neryes. 

■'■■  Localization  ^yithin  the  esophagus  is  fairly  accurate.  Lamy, 
in  his  study  of  one  hundred  and  thirty-four  cases  of  carcinoma  of 
the  esophagus,  found  that  four-fifths  of  the  patients  were  able 
to  locate  the  lesion  ^vithin  an  inch  or  two  of  the  correct  site ;  but 
in  the  remainder  a  correct  localization  was  impossible ;  often  a 
carcinoma  of  the  lower  third  would  be  located  by  the  pain-sensa- 
tions in  the  upper  third,  or  vice  versa.  Obstruction  gives  rise 
to  sensations  for  the  most  part  in  the  middle  line,  deeply  seated, 
beneath  the  sternum,  or,  if  the  obstruction  is  low  down,  in  the 
epigastrium. 


CHAPTER  XXIII 

THE    STOMACH 

After  the  review  of  the  pain-prodiicing  diseases  which  are 
located  in  the  alimentary  passages  leading  to  the  stomach,  it  is 
next  in  order  to  consider  the  pains  and  pain-producing  disorders 
of  the  stomach.  Of  late  years  there  has  been  considerable  contro- 
versy as  to  whether  the  stomach  has  pain-sensation  or  not.  The 
weight  of  the  argument  seems  to  be  on  the  side  of  those  who 
claim  that  it  has  not.  It  is  claimed  that  the  sensations  which  are 
felt  in  disease  of  the  alimentary  viscera  are  bnt  referred  sensa- 
tions or  impulses,  carried  to  the  cord  in  the  sympathetic  path- 
ways, and  thence  referred  again  to  the  periphery  through  the 
cerebrospinal  nerves. 

From  the  researches  of  Hertz  in  particular  it  would  appear 
that  the  gastric  mucosa  does  not  respond  to  tactile  nor  to  chemi- 
cal stimuli  by  pain.  The  stomach  mucosa  does  not  register 
thermal  stimuli,  and  the  sense  of  warmth  and  coolness  following 
the  ingestion  of  hot  or  cold  liquids  is  largely  due  to  the  sensi- 
bility of  the  esophagus  to  these  forms  of  stimuli.  The  sensation 
of  fulness  in  the  stomach  is  due  to  the  deep-pressure  sensibility  of 
the  muscular  coat,  and  is  brought  about  by  tension. 

The  sensation  of  hunger  and  emptiness  is  largely  a  matter  of 
habit,  associated  with  malaise  and  weakness.  It  is  conditioned 
by  the  disturbance  in  the  periodicity  of  the  muscular  hypertonus 
and  of  neuronic  excitability,  normally  the  result  of  regular  eat- 
ing. ^ 

^  According  to  W.  B.  Cannon  and  A.  L.  Washburn  (Amer.  Jour,  of  Phy- 
siology, March,  1912,  Vol.  XXIX,  p.  455),  hunger  is  due  to  the  contraction 
not  only  of  the  stomach,  but  also  of  the  lower  part  of  the  esophagus  and  the 
intestines.  They  were  able  to  prove  a  relationship  between  rhythmic  contrac- 
tions of  these  organs  and  pain  sensations, 

42e 


PAIN    CAUSED    BY    STOMACH    DISORDERS 


427 


However,  even  though  pain  in  the  stomach  is  not,  as  a  rule, 
regarded  as  true  visceral  pain,  yet  it  is  closely  related  to  it,  for  it 
may  be  due  to  the  tension  already  spoken  of  or  to  the  spread  of  the 
disease  to  surrounding  sensitive  structures,  or  to  the  traction  of  the 
peritoneal  connections.  The  accompanying  tenderness  is  most 
often  due  to  hyperalgesia  of  the  skin,  voluntary  muscles  and  con- 
nective tissues  supplied  by  that  segment  of  the  spinal  cord  which 
receives  the  incoming  stimuli  from  the  stomach  itself  and  its  con- 
tiguous structures. 

AREAS  OF  REFERRED  PAIN  CAUSED  BY  STOMACH 
DISORDERS 

The  areas  to  which  the  pain  of  stomach  disorders  are  re- 
ferred are,  first,  the  epigastrium,  and  (in  many  cases)  the  back, 
in  an  area  which,  according  to  Cumiston  and  Maylard,  is  between 
the  posterior  borders  of  both  scapulae  and  opposite  the  spinous 


Fig.  89. — Areas  of  Referred  Pain  as  Given  by  Head. 

A.  One  of  the  commonest  situations  for  pain. 

B.  One  of  the  commonest  sites  of  gastric  pain. 

C.  Maylard  gives  this  point  opposite  the  5th  dorsal  spine  as  one  of  the 

commonest  locations  of  gastric  pain. 


process  of  the  fifth  dorsal  vertehra.  The  pain  also  often  circles 
around  from  one  of  these  areas  to  the  other,  and  they  are  often 
tender  to  the  touch.  The  area  spoken  of  by  Cumiston  and  May- 
lard as  opposite  the  fifth  dorsal  spine  is  given  by  other  authori- 
ties as  opposite  the  ninth  or  tenth  dorsal  spine.     This  agrees  with 


428 


THE    STOMACH 


my  own  observations  and  coincides  more  closely  with  the  deduc- 
tions of  Head,  who  places  the  maximum  points  of  tenderness  in 
the  seventh  or  eighth  dorsal  segments,  opposite  the  ninth  and 
tenth  dorsal  spines.  Boas,  on  the  other  hand,  locates  the  area 
of.maximum  tenderness  as  opposite  the  eleventh  and  twelfth  dor- 
sal spines.  When  pain  is  produced  in  stomach  disorders,  it  may 
be  felt  in  any  of  the  areas  supplied  by  the  seventh,  eighth,  or 
ninth  dorsal  segments,   but  it  is   more  apt  to  be   felt,   and  felt 


PYLORIC   PLEXUS 


-RIGHT    VAGUS  SUPPLIES 
POST   SURFACE  STOMACH. 


I       , LEFT  VAGUS    SUPPLIES 

'       (  ANT.  SURFACE    STOMACH. 


CORONAY  PLEXUS 


--GA5TRO-EPIPL0IC 
5IN15TER- 


FiG.  90  — Nervous  Supply  of  the  Stomach. 


more  severely,  in  the  maximal  points  of  tenderness  of  these 
areas. 

In  the  accompanying  drawing  is  shown  the  nerve  supply  to 
the  stomach.  It  is  seen  to  be  both  sympathetic  (splanchnic,  celiac 
ganglion)  and  cerebrospinal  (vagus).  True  visceral  pain  is  con- 
veyed through  the  vagus,  but  it  is  of  the  deep-pressure  sensibility 
(tension)  type  allied  to  Head's  protopathic  system. 

The  areas  of  tenderness  are  of  great  diagnostic  significance. 
The  hyperalgesic  areas  (Head)  affected  in  stomach  diseases  are 
the  seventh,  eighth,  and  ninth  dorsal.  The  seventh  and  ninth 
areas  are  those  most  frequently  affected.  The  u^^per  one,  the 
seventh  dorsal,  seems  to  be  associated  particularly  with  the  stom- 
ach diseases  causing  vomiting.  AYhen  it  appears,  as  a  sequel  to 
vomiting,  it  is  frequently  accompanied  by  pain  in  the  area 
next  to  and  above  it,  namely,  the  sixth  dorsal.  The  sixth  dorsal 
area  is  associated  with  disease  in  the  lower  part  of  the  esophagus ; 


PAIN    IN    GASTRIC    AREAS  429 

consequently,  when  both  the  sixth  and  seventh  areas  are  affected 
the  disease  is  somewhere  near  to  and  probably  involves  the  esopha- 
gus. In  the  same  way  the  ninth  dorsal  area  is  shared  by  both 
the  stomach  and  the  intestines,  and  when  both  are  affected  the 
lesion  is  probably  in  the  neighborhood  of  the  pylorus.  When  the 
seventh  dorsal  is  involved,  the  pain,  as  a  rule,  comes  on  within 
half  an  hour  after  taking  food ;  while,  if  the  eighth  dorsal  is  in' 
volved,  the  pain  generally  comes  on  at  least  an  hour  later. 

By  stimulating  the  area  in  the  hypogastrium,  which  is  hyper- 
algesic,  a  reflex  contraction  of  the  upper  segment  of  the  recti 
takes  place.  While  in  some  cases  only  a  segment,  in  others  the 
entire  rectus  is  thrown  into  contraction. 

That  the  area  in  which  pain  is  felt  in  stomach  diseases  does 
not  necessarily  correspond  to  the  site  of  the  gastric  lesion,  may  be 
seen  from  the  drawing  (Fig.  98),  where  the  projected  outline  of 
the  stomach  is  shown,  with  the  dark  circle  indicating  the  area 
of  tenderness  in  gastric  ulcer,  the  tenderness  in  no  case  being 
directly  over  the  stomach. 

PAIN  IN  GASTRIC  AREAS 

When  pain  occurs  in  the  gastric  areas,  it  is  necessary  to  in- 
quire into  the  following  :  (1)  the  character  of  the  pain;  (2)  the 
time  and  manner  of  its  appearance;  (3)  its  relation,  if  any,  to 
the  ingestion  of  food;  (4)  the  duration  of  the  pain;  and  (5)  pre- 
vious attacks. 

Character  of  Gastric  Pain. — Certain  types  of  gastric  lesiois 
have  characteristic  pains;  for  instance,  that  of  gastritis  is  bur:.- 
ing;  that  of  spasm  of  the  pylorus  is  sharp  and  sudden;  that  of 
ulcer  is  very  severe  and  is  sharply  circumscribed;  that  of  per- 
foration is  sharp  and  agonizing,  and  quickly  spreads  from  the 
site  of  its  original  location;  that  of  acute  dilatation  is  severe 
and   constant,   and  is  accompanied  by   symptoms  of  collapse. 

It  should  also  be  borne  in  mind  that  the  severity  of  the  pain 
has  no  proportionate  relation  to  the  gastric  conditions,  but  often,  as 
in  pain   caused  by   lesions   in  other   organs,    dejjends   upon   the 


430  THE    STOMACH 

susceptibility  of  the  nervous  system  and  the  sensitiveness  of  the 
pain-receptive  centers  of  the  individual  patient. 

Time  and  MaJiner  of  Its  Appearance. — Should  the  onset  be 
sudden,  without  any  apparent  exciting  factor  and  without  any 
previous  history  of  pain,  perforating  ulcer  or  pyloric  spasm  is 
to  be  considered.  In  perforating  ulcer  associated  symptoms  of 
collapse  and  spreading  peritonitis,  with  a  diffusion  and  constant 
increase  of  the  pain,  would  be  present,  while  in  pyloric  spasm 
irregular  paroxysmal  pains  that  are  sharply  localized  with  no 
tendency  to  spread  or  to  become  generalized  would  be  present. 

Acute  gastritis  is  associated  with  the  vomiting  of  indigestible 
or  fermenting  substances ;  this  generally  tells  the  tale.  If  the 
pain  is  of  slow  onset,  and  there  are  at  first  discomfort,  and 
then  a  gradually  increasing  distress  until  well-marked  pain  is 
present,  particularly  if  the  pain  is  associated  with  the  vomiting 
of  blood  (coffee-ground  vomitus),  it  is  necessary  to  examine 
for  gastric  carcinoma. 

Relationship  to  Ingestion  of  Food. — If  the  pain  comes  on  at 
a  definite  time  after  eating,  and  is  relieved  by  vomiting,  gastric 
ulcer  is  thought  of.  If  it  comes  on  immediately  after  eating,  the 
cardiac  end  is  affected ;  on  the  other  hand,  if  it  does  not  appear 
for  an  hour  or  two  after  eating,  ulcer  of  the  pylorus  is  to  be  con- 
sidered. If,  instead  of  coming  on  immediately,  it  makes  its  ap- 
pearance one-half  to  two  hours  after  eating,  carcinoma  or  hyper- 
chlorhydria  should  be  considered.  In  carcinoma  the  coffee- 
ground  vomit  is  distinctive,  while  in  hyperchlorhydria  the  excess 
of  hydrochloric  acid,  with  the  absence  of  blood,  is  sufficient  to 
make  a  diagnosis.  In  early  carcinoma,  pain  and  coffee-ground 
vomit  are  absent.  Hyperchlorhydria  may  occur  from  gall-blad- 
der disease,  duodenal  ulcer,  or  be  purely  functional. 

Duration  of  Pain. — The  duration  of  the  pain  in  any  of  the 
gastric  disorders  is  variable.  It  seems  to  be  present  more  con- 
stantly and  for  a  greater  length  of  time  in  those  disorders  which 
have  an  organic  basis  for  their  production.  In  carcinoma  the 
pain  is  steady  and  persistent,  while  in  hyperchlorhydria  and 
pyloric  spasm  it  is  associated  with  the  ingestion  of  food, 


LESIONS    or    STOMACH    CAUSING   PAIN  431 

Previous  Attacks.  — A.  history  of  previous  attacks  of  pain  may 
be  of  value,  in  that  it  often  is  confirmative  of  the  diagnosis  vehich 
the  present  symptoms  would  suggest. 

Associated  Symptoms. — Constipation  is  generally  associated 
with  gastric  ulcer,  hyperacidity,  and  carcinoma. 

Pain  Reflected  or  Referred  to  Gastric  Areas. — When  pain  is 
present  in  the  gastric  areas,  it  may  be  not  of  gastric  but  of 
nervous  origin  (intercostal  neuralgia)  ;  or  it  may  be  projected  from 
the  cord  (locomotor  ataxia,  general  paralysis,  disseminated  scle- 
rosis), or  it  may  be  a  reflex  from  other  organs,  as  the  uterus,  kid- 
ney, intestines,  appendix,  gall-bladder,  pancreas,  heart,  or  prostate. 

LESIONS  OF  STOMACH  CAUSING  PAIN 

The  commoner  lesions  of  the  stomach  causing  pain  are:  (1) 
displacement;  (2)  gastralgia;  (3)  hyperchlorhydria ;  (4)  cardiac 
or  pyloric  spasm;  (5)  acute  dilatation;  (6)  acute  gastritis;  (7) 
chronic  gastritis;  (8)  gastric  erosions;  (9)  gastric  ulcers;  (10) 
perforating  ulcer;  (11)  new  growths,  and  (12)  perigastric  ad- 
hesions. 

Displacement  of  the  stomach  (gastr ©ptosis)  generally  causes 
no  pain  until  it  induces  a  dilatation.  Then  the  sensation 
produced  is  rather  a  disagi'eeable,  nauseating  feeling  than 
a  true  pain.  It  is  increased  by  eating  or  by  standing,  and  is 
decreased  on  lying  down  or  on  supporting  the  abdomen  by  a 
bandage  judiciously  applied. 

Gastralgia  or  Gastromyalgia. — By  many  gastralgia  is  dis- 
claimed as  a  misnomer,  because  it  is  said  that  there  is  no  such 
pathological  entity.  But  why  ?  The  stomach  is  an  organ  whose 
walls  consist  of  muscular  tissue,  and  why  should  not  this  tissue, 
even  though  it  is  involuntary,  be  subject  to  the  same  metabolic 
disturbances  as  are  the  muscles  of  the  back,  which  under  abnor- 
mal metabolic  changes  give  rise  to  lumbago?  The  only  differ- 
ence is  that  in  the  affected  back  muscle  the  changes  act  princi- 
pally on  the  terminations  of  sensory  nerves  in  the  muscles,  while 
in  the  stomach  walls  the  nerve  terminals  affected  are  not  sensitive 
in  the  meaning  that  they  convey  pain  or  touch  sensation.     There- 


432  THE    STOMACH 

fore,  for  this  irritation  to  be  perceived  as  harmful,  that  is,  painful, 
it  must  be  carried  to  the  cord,  where,  irritating  some  sensory 
neuron,  the  stimulus  is  carried  to  the  brain,  where  it  is  perceived 
as  coming  from  the  area  of  distribution  of  this  neuron.  That  such 
a  changed  metabolic  and  at  the  same  time  pain-producing  lesion 
may  exist  in  the  stomach  is  in  accord  with  the  opinion  of  the 
majority  of  observers.  The.  condition,  instead  of  being  termed 
gastralgia,  which  is  only  a  general  term,  should  be  called  gastro- 
myalgia,  although  the  term  gastralgia  is  still  in  general  use. 

Schmidt  claims  that  "the  existence  of  true  gastralgia  result- 
ing from  purely  anatomical  and  functional  disturbances  is  as  cer- 
tain as  the  pain  of  dental  caries."  Maylard  describes  it  as  "oc- 
curring generally  in  those  of  a  neurotic  taint ;  and  the  pain  may 
be  of  the  most  excruciating  character,  seizing  the  patient  in  the 
epigastrium,  and  striking  through  to  the  back,  radiating  some- 
times round  the  chest  or  waist."  It  is  most  erratic  in  the  time  of 
its  appearance.  Sometimes  it  follows  the  ingestion  of  food,  while 
at  other  times  it  appears  without  any  kno^\Ti  cause.  It  may 
sometimes  appear  periodically  at  night,  and  at  other  times  it  may 
follow  upon  any  excessive  draft  upon  the  nervous  system  by 
worry  or  excitement.  The  pain  is  "generally  out  of  all  proportion 
to  other  physical  symptoms  of  any  suggestive  physical  disease. 
The  patient  may  also  compkin  of  a  beating  sensation,  pulsating 
sensation,  a  feeling  of  heat  or  cold.  Periods  of  pain  generally 
alternate  with  periods  of  complete  freedom  from  it."  ^ 

The  symptoms  usually  associated  with  this  condition  are  flatu- 

*  This  consideration  of  the  subject  differs  markedly  from  that  given  by 
Schmidt,  who  classifies  all  gastralgias  as  neuralgic  in  origin.  While  it  must  be 
admitted  that  stomach  pain  depends  upon  the  irritation  of  nerve  terminal  fila- 
ments for  its  production,  yet,  as  mentioned  above,  in  a  somewhat  though  not 
entirely  similar  condition  in  the  voluntary  muscles,  the  term  myalgia  is  used. 
It  seems  that  an  analogous  term,  such  as  gastro myalgia,  should  be  used  for 
pain  having  its  origin  in  the  stomach  musculature.  The  general  term  gastral- 
gia, therefore,  is  ill-fitted,  and  is  only  to  be  used  in  a  general  way  to  include 
those  pains  originating  in  the  stomach,  the  etiology  of  which  cannot  be  defi- 
nitely determined. 

On  the  other  hand,  neuralgia  of  the  stomach  is  entirely  different  in  its 
etiology  from  gastromyalgia,  but  is  included,  as  are  all  stomach-productive 
pains  of  unknown  etiology,  under  the  generic  term  ' '  gastralgia. ' ' 


LESIONS    OF    STOMACH    CAUSING    PAIN  433 

lence,  distention,  anorexia,  cravings  for  food,  vomiting,  and  py- 
rosis. The  stomach  j)ains  frequently  alternate  with  attacks  of 
migraine  (same  as  in  angina  pectoris),  neuralgia  of  the  head,  and 
asthma.  Women  are  more  j^rone  to  gastromyalgia  than  men,  in 
the  proportion  of  two  to  one,  and  it  is  most  common  between  the 
ages  of  twenty  and  forty-five. 

In  an  entirely  different  class,  but  slightly  related  to  the 
pains  we  have  just  described,  are  those  due  either  to  a  secretory 
or  a  motor  disturbance.  These  will  be  considered  later  under 
their  proper  headings.  In  the  meantime  it  is  well  to  remem- 
ber, in  considering  the  cause  of  stomach  j)ain,  that  the  lessened 
resistance  of  the  nervous  system  to  pain-production  is  of  mani- 
fest importance.  Some  people,  owing  to  disease  or  inherited  pre- 
disposition, are  abnormally  sensitive  to  pain,  so  that  the  percep- 
tion of  sensations,  wdiich  in  others  ordinarily  would  not  even  be 
disagreeable,  w'ould  be  felt  by  them  as  sensations  varying  all  the 
way  from  distress  to  actual  ^^ain.  In  this  connection  it  is  helpful 
to  know  that  gastric  pains  not  of  purely  nervous  origin  are  influ- 
enced by  the  ingestion  of  food  and  the  position  of  the  patient,  while 
those  of  purely  nervous  origin  are  not. 

The  diseases  acting  as  predisposing  causes  of  gastromyalgia 
or  gastroneuralgia  are  about  the  same  as  those  which  cause  a 
lessened  resistance  in  the  nervous  system,  and  which  are  pro- 
ductive of  cerebrospinal  neuralgia.  Among  them  may  be  men- 
tioned anemia  (chlorosis),  infectious  diseases,  rheumatism,  syph- 
ilis, influenza,  tuberculosis,  excessive  use  of  stimulants  (alcohol, 
tea),  sexual  over-indulgence,  gout,  diabetes,  uremia,  and  physical 
depression. 

The  reflexes  which  are  sometimes  felt  as  pain  in  the  gastric 
reference  area,  and  which  in  some  cases  are  even  accompanied 
by  vomiting,  will  be  considered  under  the  reflex  pains  of  the  appro- 
priate viscera,  though  for  clearness  of  conception  they  will  also 
be  described  in  our  consideration  of  the  diagnosis  of  stomach 
pains.  These  reflex  pains  in  the  epigastrium,  associated  with 
vomiting  are  due  to  disease  of  the  gall-bladder,  pancreas,  appen- 
dix, uterus  and  appendages,  etc.,  should  not,  as  is  done  by  some 


434  THE    STOMACH 

authors,  be  placed  under  gastralgia,  but  should  be  considered 
under  the  lesions  of  the  different  organs  producing  them.  This 
is  sometimes  very  difficult,  for,  in  many  cases,  it  is  not  easy  to 
distinguish  the  origin  of  the  different  pains;  for  instance,  gall- 
stone colic  is  often  confused  with  gastric  pain,  yet  it  may  be  dis- 
tinguished from  it  by  its  paroxysmal  character,  its  tendency  to 
become  localized  to  the  right  and  to  extend  around  the  right  side 
to  the  area  underneath  the  right  scapula.  At  the  same  time  it  is 
associated  with  localized  gall-bladder  tenderness,  and  often  there  is 
a  well-marked  enlargement  of  the  gall-bladder  and  sometimes  a 
generalized  jaundice.  Angina  jDectoris  has  also  been  confused  with 
gastric  pain.  Here  the  pain,  as  a  rule,  follows  exertion,  and  radi- 
ates into  the  left  arm  and  hand.  The  heart  may  be  tumultuous  in 
action,  and  frequently  there  are  severe  depression  and  a  fear  of 
death.  The  appendix,  also,  has  in  many  cases  been  found  to 
cause  epigastric  pains;  but  here  epigastric  pain,  with  no  tender- 
ness over  the  epigastrium,  but  over  the  appendiceal  region,  is 
present.  There  may  also  be  a  palf)able  mass  in  the  same  region, 
and  the  pain  and  tumor  are  associated  with  vomiting,  eructation 
of  gas  and  constipation.  Of  diagnostic  importance  in  differenti- 
ating pain  of  local  origin  from  referred  pain  is  the  administra- 
tion of  local  anodynes,  as  cocain,  alypin,  menthol,  and  f)henol. 
These  generally  cause  the  pain  to  lessen  or  cease  when  it  is  of 
local  irritative  origin,  such  as  occurs  when  the  lesion  is  in  the 
mucous  membrane,  namely,  in  ulcer,  carcinoma,  etc.  When  no 
effect  is  noticed,  after  the  administration  of  the  local  anodyne, 
neurotic  lesions  should  be  considered.  Of  considerable  diag- 
nostic importance  is  the  fact  that  gastromyalgia  is  frequently 
relieved  by  pressure. 

Hyperchlorhydria.  — Hyperchlorhydria  is  the  only  secretory 
neurosis  of  the  stomach  which  j^roduces  pain.  This  pain  comes 
on  one-half  to  two  hours  after  eating,  and  lasts  a  few  hours,  or 
until  more  food  is  taken,  being  particularly  relieved  by  the  in- 
gestion of  proteids,  and  also  by  alkalies.  It  is  much  less  after 
large  meals,  especially  those  containing  much  meat  and  eggs  and 
deficient   in  carbohydrates.     The  pain  differs  from  that  due  to 


LESIONS    OF    STOMACH    CAUSING   PAIN 


435 


gastric  ulcer  in  being  diffuse  and  extending  over  the  entire  abdo- 
men. It  seems  to  be  frequent  in  persons  of  neurotic  tempera- 
ment, and  is  commonly  associated  with  gall-stones,  Hyj^er- 
chlorhydria  is  also  frequently  associated  with  neurotic  motor 
disturbances.     The  pain  produced  by  it  often  is  accompanied  by 

This  substernal  pain  represents  the 
esophageal  component  of  the  pain 
symptoms 

/ 


Tenderness  on  deep 
pressure 


'Area  of  hyperalgesia  to 
pin  point  pressure. 
Over  this  area  there  is 
J  also  pain  to  deep  pres- 
sure.  It  lies  about  the 
junction  of  the  7th  left 
costal  cartilage  with  the 
7th  rib 

Fig.   91. — Location  of  the  Pain  Symptoms  in  a  Case  of  Hyperchlor- 

HYDRIA. 


a  considerable  belching  of  gas,  generally  preceded  by  a  burning 
sort  of  pain,  which  seems  to  run  up  under  the  sternum  to  the 
throat,  and  is  accompanied  by  the  regurgitation  of  acid-tasting 
fluid.  The  pain  may  also  radiate  to  the  back,  to  the  axilla,  and 
to  the  scapula.  In  some  instances  the  pain  seems  to  be  due  to 
the  presence,  even  in  small  quantities,  of  hydrochloric  acid.  In 
these  j3atients  there  is  a  peculiar  antipathy  of  the  stomach  to  the 
presence  of  any  acid.  The  examination  of  the  stomach  contents 
often  shows  a  normal  or  even  a  subnormal  percentage  of  acid. 

Hertz  has  shown  that  the  gastric  mucosa  is  not  painfully 
stimulated  by  excess  of  hydrochloric  or  other  weak  acids.  It  is 
probable  that  the  heartburn  of  so-called  hyperchlorhydria  has 
nothing  whatever  to  do  with  acid  production,  and  that  the  term 
is  a  misnomer.  The  hot  sensation  is  closely  related  to  that  felt 
following  the  ingestion  of  alcohol,  and  is  felt  most  often  following 
slight  regurgitation  due  to  the  presence  of  excessive  amounts  of 
gas.     Hertz  maintains  that  heartburn  is  an  esophageal  sensation, 


436 


THE   STOMACH 


not  a  gastric  one,  and  is  due  to  the  stimulus  of  excessive  carbo- 
hydrate fermentation  (hot  bread — biscuit — causing  the  so-called 
pudding  heartburns).  This  causes  the  jjroduction  of  alcohols, 
ethers,  and  organic  acid  in  the  stomach,  which  by  regurgitation 


Fig.  92.— Pain  Radiation. 

Crosses  indicate  the  sites  of  pain  and  the  Unas  with  arrows  indicate  the 

direction  of  the  pain  radiation. 

act  upon  the  lower  end  of  the  esophagus,  thus  giving  rise  to  the 
classical  heartburn  erroneously  interpreted  as  a  hyperchlorhydria. 
For  a  further  interpretation  of  the  causes  of  pain  in  hyperchlor- 
hydria, see  gastric  ulcer. 

Pyloric  or  Cardiospasm. — The  stomach  resembles  other  divi- 
sions of  the  hollow  abdominal  viscera  in  that  it  is  subject  to  colic; 
but  the  j)arts  chiefly  affected  are  the  pylorus  and  the  cardia,  as 
the  intervening  portion  has  so  great  a  lumen  that  it  contracts  en 
bloc  less  readily.  Then,  too,  this  part  of  the  stomach  is  so  situated, 
and  its  attachments  to  the  adjacent  viscera  are  so  arranged,  that  it 
may  undergo  considerable  distention  without  any  symptoms  being 
produced ;  but  as  soon  as  the  distention  becomes  excessive  and  trac- 
tion is  made  on  its  peritoneal  and  diaphragmatic  attachments, 
pain  results.  The  same  is  true,  when,  owing  to  the  contraction 
of.  the  pylorus  or  cardia,  a  change  in  the  relationship  of  these  two 
parts  to  the  surrounding  viscera  results,  and  a  pull  on  their  peri- 
toneal attachments  occurs. 


LESIONS    OF    STOMACH    CAUSING   PAIN  437 

By  reference  to  the  anatomy  it  is  seen  bow  the  cardia  of  the 
stomach  is  immediately  below  the  opening  in  the  diaphragm,  and 
how,  when  it  contracts,  especially  when  the  stomach  is  full,  there 
must  be  a  stretching  of  the  gastrophrenic  ligament,  with  resulting 
pain.  The  same  is  true  of  the  pylorus,  but  here  the  pull  is  made 
on  the  gastrohepatic  omentum,  and  possibly  also  on  the  gastro- 
colic omentum.  Hertz  claims  that  the  pains  in  pyloric  or  cardiac 
spasm  are  really  tension  pains,  due  to  distention  of  a  seg-ment 
of  the  stomach.  In  pyloric  si:>asm  a  persisting  contraction  of  the 
pylorus  occurs  as  a  reflex  from  the  j^rcsence  of  an  excess  of  HCl 
in  the  stomach.  The  peristaltic  wave  in  the  stomach,  being  ex- 
cessive from  the  HCl  stimulation,  pushes  the  food  onward  i::itil 
it  reaches  the  prepyloric  part  of  the  stomach ;  from  here,  owing 
to  the  closure  of  the  pylorus,  it  cannot  advance  further,  and 
tension  is  made  upon  the  stomach  walls  at  this  point. 

From  this  it  would  seem  that  not  only  is  the  small  part  of  the 
stomach  at  the  pylorus  involved,  but  that  also  a  large  part,  if  not 
the  entire  stomach  musculature,  is  involved  in  the  contraction.  It 
is  hardly  probable  that  the  contraction  of  the  constricted  part  of 
the  bowel  at  the  pylorus  could  so  alter  the  relationship  of  this  one 
part  to  the  gastrohepatic  or  gastrocolic  omentum  that  the  stretching 
of  it  would  be  gTeat  enough  to  cause  the  severe  and  widely  diffused 
epigastric  pain  which  is  sometimes  present.  Another  argument  in 
favor  of  the  participation  of  the  muscular  wall  is  that  the  pain  is 
relieved  by  vomiting. 

A  somewhat  similar  cause  exists  for  the  pain  in  hour-glass 
stomach.  Here  a  portion  of  the  stomach  is  contracted,  and  an  hour- 
glass stomach  results.  The  food  entering  the  upper  compartment 
is  pushed  forward  by  the  peristaltic  waves  until  it  reaches  the  place 
of  contraction;  here  it  is  unable  to  jirogress  further,  and  at  this 
point  tension  is  made  on  the  gastric  walls,  and  pain  results.  As 
would  be  exjiected,  the  jiain  is  not  felt  when  the  stomach  is  empty, 
but  results  only  after  ingestion  of  food  and  drink.  It  is  relieved 
by  vomiting. 

The  cause  of  pain  in  cardiosjoasm  is  the  dilatation  of  the  ter- 


438  THE    STOMACH 

minal  portion  of  the  esoiihagus.  This  is  the  result  of  stasis  of 
food,  due  to  spasmodic  closure  of  the  cardiac  sphincter.  In  cardio- 
spasm the  pain  comes  on  immediately  after  eating,  is  fairly  con- 
stant, and  seems  to  be  located  beneath  the  costal  margin  at  the  left 
seventh  costal  cartilage,  while  in  pyloric  spasm  the  pain  is  localized 
in  the  midline,  about  midway  between  the  umbilicus  and  ensiform, 
and  comes  on  two  or  three  hours  after  eating,  i.  e.,  at  the  time  of  the 
passage  of  the  gastric  contents  through  the  pyloric  opening.  Both 
pains  have  a  typical  paroxysmal  grijDping  or  twisting  character, 
and  are  equally  severe.  The  pyloric  spasm  generally  is  relieved 
by  vomiting,  while  cardiospasm  gradually  passes  off,  no  vomiting, 
as  a  rule,  occurring.  In  both  midnight  attacks  are  very  frequent. 
It  seems  also  that  in  some  cases  the  contraction  of  the  cardiac  and 
pyloric  sphincters  alone  can  cause  reflected  pain,  this  pain  being 
due  to  the  unusual  squeezing  of  the  nerve  terminals  in  the  muscular 
tissue,  the  result  of  the  abnormally  severe  contraction.  For  the 
production  of  pyloric  spasm  pain  it  is  not  always  necessary  that 
the  stomach  be  full,  for  in  many  cases  when  it  is  empty  the  irrita- 
tion of  the  gastric  secretions  (which  in  this  condition  are  often 
highly  acid)  will  produce  it.  Also,  it  can  be  relieved  by  washing 
out  the  stomach. 

A  similar  contraction  of  the  musculature  of  the  pylorus  and, 
in  some  cases,  of  the  entire  stomach  and  duodenum  is  the  cause 
of  hunger-pain.  This  differs  from  card i a  and  jiyloric  spasm  in 
that  it  can  be  relieved  by  the  ingestion  of  food,  provided  the 
stomach  mucosa  and  musculature  are  intact.  The  ingestion  of 
food  will  not  relieve  the  associated  hunger-pain  present  in  ulcer 
or  carcinoma  of  the  stomach,  because  the  food,  of  itself,  is  an  irri- 
tant in  such  conditions,  and  aggravates  instead  of  easing  the 
spasm. 

In  all  these  conditions,  after  the  pyloric  spasm  has  persisted 
for  some  time,  a  dilatation  of  the  stomach  results.  This  dilata- 
tion, in  turn,  causes  gastric  pain,  because  of  the  traction  and 
pull  of  the  gastric  walls  on  the  omental  attachments.  The  pain 
is  of  the  same  kind  as  described  in  acute  dilatation  of  the  stom- 


LESIONS    OF    STOMACH    CAUSING   PAIN  439 

ach,  only  in  dilatation  the  result  of  pyloric  spasm  the  pain  is 
added  to  the  previously  existing  spasm  pain.  In  acute  dilatation 
also,  the  pain  is  more  generalized,  and  becomes  constant,  while  the 
pyloric-spasm  pain  is  paroxysmal.  In  case  of  dilatation  of  the 
stomach  the  epigastrium  is  distended,  the  outlines  of  the  stom- 
ach are  plain,  and  visible  gastric  peristalsis  can  be  seen;  also, 
on  listening,  borboryg-mi  and  bubbling  noises  can  be  heard. 
Succussion  sometimes  gives  rise  to  a  splashing  sound.  Eructa- 
tions of  sour-tasting  fluid  are  also  present.  These  associated 
symptoms  generally  come  on  when  the  pain  is  most  severe.  If 
vomiting  occurs,  and  the  spasm  has  been  of  some  duration, 
large  quantities  of  gastric  contents  are  expelled.  Sometimes 
the  attacks  of  colic  are  accompanied  by  a  mild  chill  of 
nervous  origin,  elevation  of  the  temperature  being  entirely 
absent. 

Pressure  on  the  distended  stomach  is  well  borne,  and  is  fre- 
quently applied  by  the  patient,  because  it  seems  to  aid  in  the  forc- 
ing on  of  the  stagnated  stomach  contents.  The  pain  is  increased 
by  the  eating  of  indigestible  foods.  According  to  Schmidt,  cold 
applications  to  the  epigastrium  seem  to  be  better  borne  than  hot 
ones,  and  to  be  more  beneficial  to  the  patient. 

Acute  Dilatation  of  the  Stomach. — Acute  dilatation  of  the 
stomach  frequently  is  a  cause  of  the  most  severe  pain.  It  is  prone 
to  occur  after  operations,  especially  those  in  which  there  has  been 
considerable  handling  of  the  abdominal  viscera.  It  comes  on, 
as  a  rule,  three  or  four  days  following  the  operation.  By  many 
it  is  held  to  be  only  a  symptom  of  a  peritonitis,  which,  it  is 
claimed,  is  present  in  every  case  of  such  vomiting.  At  first  there 
is  a  feeling  of  distress  in  the  epigastrium,  which  soon  increases 
until  severe  pain  is  felt.  This  is  generally  accompanied  by  the 
vomiting  of  a  greenish  fluid,  and  by  a  gradual  abdominal  disten- 
tion, with  rise  of  pulse  rate,  and  signs  of  severe  systemic  distress. 
This  state,  unless  relieved,  is  rapidly  fatal.  Acute  dilatation  also 
occurs  in  many  patients  who  have  not  been  subjected  to  operative 
interference,  but  generally  it  is  not  of  as  severe  a  form  as  in  the 


440  THE    STOMACH 

operative  ones.  In  both  of  these  conditions  the  pain  is  of  a  diffuse 
nature,  and  is  located  in  the  epigastrium.  Because  of  the  acid  con- 
dition of  the  stomach  contents,  the  pain  may  be  partially  relieved 
by  the  ingestion  of  alkalies;  but  the  only  sure  relief  is  from  re- 
peated stomach  washing.  Should  stomach  distention  be  suspected, 
it  can  be  confirmed  or  disproved  by  percussion  and  palpation,  as 
well  as  by  the  stomach  tube,  by  which,  if  gastric  dilatation  is 
present,  large  quantities  of  greenish  fluid  may  be  removed. 

In  some  cases  distention  of  the  stomach  may  be  associated 
with  distention  of  the  duodenum,  and,  when  this  occurs,  as  in  a 
case  reported  by  Torrance  (577),  there  may  be  pain  under  the 
right  shoulder  and  over  the  eighth  and  ninth  ribs  to  the  right  of 
the  spinal  column. 

The  pain  of  gastric  dilatation  is  also  partially  due  to  the  trac- 
tion which  the  diaphragm  exerts  on  its  costal  attachments,  owing 
to  the  upward  force  exerted  upon  it  and  its  consequent  displace- 
ment by  the  distended  stomach. 

Acute  Gastritis. — Although  the  stomach  has  no  special  tactile 
sensory  nerves,  it  reacts  painfully  to  inflammatory  lesions. 
When  inflammation  is  present  in  the  stomach  walls,  the  adjacent 
lymphatics  become  involved,  lymphangitis  results,  and  this  in- 
flammation spreads  to  the  parietal  peritoneum  through  the  im- 
mediate attachments,  and  causes  it  to  become  hypersensitive.  At 
the  same  time  the  inflammation  of  its  walls  causes  the  stomach 
to  become  very  irritable,  and  to  react  much  more  strongly  than 
usual  to  stimuli;  so  that,  on  the  entrance  of  food  and  drink,  it 
contracts  to  a  greater  than  normal  degree.  This  produces  trac- 
tion much  greater  than  normal  on  the  inflamed  mesentery,  and  at 
the  same  time  causes  tension  within  its  own  muscular  coat  and 
pressure  upon  the  nerves  of  deep  sensibility  with  resultant  pain. 

In  gastritis  the  subjective  pain  is  felt  in  the  epigastrium,  and 
at  the  same  time  the  gastric  areas  of  hyperalgesia  (Head)  may 
be  present.  The  subjectiv^e  pain  is  of  a  dull,  aching  character, 
increasing  to  a  sharp,  burning  on  the  ingestion  of  foods.  Another 
characteristic  of  this  pain  is  that  it  seems  to  run  directly  through 


LESIONS    OF    STOMACH   CAUSING   PAIN 


441 


to  the  back,  this  being  most  probably  the  result  of  the  irritation 
of  the  inflamed  peritoneum  around  the  cardiac  opening,  which 
lies  very  much  closer  to  the  back  than  it  does  to  the  anterior 
abdominal  wall.  On  making  pressure  over  the  epigastrium,  pain 
is  elicited;  light  pressure  bringing  out,  in  many  cases,  the  hyper- 


rPain  in  epigastrium  goes 

directly  through  to  the 

■<  back.    Pain   between 

shoulders  is  also  some- 

Ltimes  present 


Fig,  93. — Figube  Illustrating  the  Location  of  Pain  in  Acute  Gastritis. 


algesic  areas  of  Head,  while  deep  pressure  brings  to  light  the 
tenderness  of  the  subserous  peritoneum,  which,  because  of  its 
lymphatics,  is  frequently  involved  in  the  inflammatory  process. 
This  pain  varies  in  intensity  and  seems  to  have  some  relationship 
with  the  severity  of  its  lesion,  so  that  the  extent  of  the  gastric 
inflammation  may  partially  be  judged  from  the  magnitude  of  the 
pain. 

The  pain  of  acute  gastritis  is  fairly  sudden  in  its  onset.  It 
may  follow  a  night  of  alcoholic  indulgences,  or  occur  after  the 
eating  of  indigestible  substances,  and  is  associated  with  nausea 
and  vomiting.  It  may  be  so  severe  that  morphin  is  required  to 
relieve  it.  In  some  cases  there  is  an  elevation  of  the  tempera- 
ture as  high  as  104  °  F.  and  an  increased  rapidity  of  the  pulse. 
The  recti  muscles  of  the  upper  abdomen  are  also  contracted  (es- 
pecially on  the  left  side)  and  are  slightly  tender  on  palpation. 


442  THE    STOMACH 

Chronic  Gastritis. — Chronic  gastritis  is  generally  not  painful, 
though  after  eating  there  may  be  a  feeling  of  discomfort.  Rie- 
gel,  according  to  Gilbride,  claims  that  in  the  atrophic  forms  of 
gastritis  the  pain  resembles  that  of  the  gastric  crisis  of  tabes. 

Gastric  Erosions.- — Gastric  erosions,  as  pathological  entities, 
occupy  a  position  intermediate  to  gastritis  and  ulcer.  Pathologi- 
cally they  are  less  extensive  than  ulcers,  and  more  intensive  than 
gastritis.  The  pain  produced  is  of  a  dull  aching  character,  and 
seems  to  extend  throughout  the  entire  stomach  area.  It  is  not 
affected  by  pressure  or  by  change  of  position.  It  generally  comes 
on  after  eating,  persists  an  hour  or  two,  and  then  gradually  sub- 
sides; but  it  may  be  present  irrespective  of  the  intake  of  food, 
and  intervals  may  be  present  in  which  there  is  absolutely  no  pain. 
The  course  of  the  disease  is  prolonged.  Emaciation,  loss  of  appe- 
tite, and,  in  many  cases,  hematemesis  may  result. 

Gastric  Ulcer. — Gastric  ulcer,  in  its  pain  production,  depends 
upon  practically  the  same  factors  as  does  gastritis.  The  lesion 
in  ulcer  is  circumscribed,  w^hile  that  of  gastritis  is  diffuse.  Both 
are  associated  with  lymphangitis,  and  it  is  this  lymphangitis 
which  contributes  greatly  to  the  pain  that  is  produced.  That  the 
pain  and  tenderness  which  are  felt  on  palpation  are  not  present  in 
the  stomach  but  in  the  abdominal  wall  can  be  demonstrated  from 
the  following  premises : 

(1)  The  ulcer,  in  most  cases,  is  on  the  posterior  wall  of  the 
stomach,  and  pressure  upon  it  through  the  abdominal  wall,  rigid 
because  of  the  contraction  of  the  rectus,  is  almost  impossible. 

(2)  The  pain  and  tenderness  are  constant,  while  the  relative 
position  of  the  ulcer  is  always  varying,  depending  upon  move- 
ment of  the  stomach  due  to  respiration,  peristalsis,  distention 
with  food,  liquids,  gas,  etc. 

(3)  On  exposure  of  the  stomach  by  exploratory  laparotomy 
the  ulcer  may  not  be  found  immediately  beneath  the  area  in  which 
the  pain  and  tenderness  had  been  felt. 

In  the  following  drawing,  Mackenzie  (586)  illustrates  the 
relative  position  of  the  pain  and  the  site  of  the  ulcer.     In  his 


LESIONS    OF    STOMACH    CAUSING   PAIN 


443 


cases  the  site  of  the  ulcer  bore  no  relationship  to  the  site  of  the 
pain;  but  when  the  ulcer  was  near  the  cardiac  end  of  the  stom- 
ach the  localized  pain  and  the  cutaneous  and  muscular  hyperal- 
gesia were  situated  high  in  the  epigastrium,  while  if  the  ulcer 
was  situated  near  to  the  pylorus 
it  caused  pain  low  down  in  the 
epigastric  region. 

It  is  claimed  that  in  some 
cases  it  is  the  contraction  of  the 
pylorus  which  causes  pain;  in 
others  that  it  is  the  contraction 
of  the  bundle  of  fibers  which 
surrounds  the  prepyloric  region 
of  the  stomach  and  separates  the 
antrum  pylori  from  the  rest.  In 
one  case  Moullin  reports  a  cure 
from  the  ulcerated  condition 
and  the  pain  by  section  of  these 
fibers  (Mansell  Moullin,  578). 

In  this  case  neither  ulcer 
nor  scar  could  be  found  when 
the  stomach  was  opened,  so  that 
it  was  probably  only  a  case  of 
hypertrophied  pylorus. 

That  the  pain  in  gastric 
ulcer  is  not  due  to  hyperacidity  of  the  stomach  contents  can  be  de- 
duced from  the  fact  that  increase  in  the  hyperacidity,  due  to  the 
ingestion  of  acids,  produces  no  increase  in  the  pain.  It  has  also 
been  shown  that  pain  cannot  be  produced  by  irritation  of  the  nor- 
mal mucous  surface  of  the  stomach.  The  researches  of  Hertz  also 
tend  to  show  that  an  ulcerated  surface  is  insensitive  to  acids  in  the 
strength  found  in  the  stomach. 

In  some  patients  an  ulcer  of  the  stomach  causes  no  pain. 
When  this  occurs  the  ulcer  is  generally  situated  on  the  anterior 
surface,  near  to  the  cardia,  no  adhesions  having  formed  between 
it  and  the  parietal  peritoneum.     C.  W.  Habershon,  in  1859,  was 


Fig. 


IN 


94.  —  Location  of  Pain 
Gastric  Ulcer. 
In  the  figure  the  area  A  shows  the 
area  of  pain  when  the  ulcer  was 
at  the  cardiac  end  of  the  stomach 
a;  B  when  the  ulcer  was  in  the 
middle  of  the  lesser  curvature  b; 
C  when  the  ulcer  was  at  the 
pylorus  c. 


444  THE    STOMACH 

one  of  the  first  to  show  that  ulcer  confined  to  the  mucous  mem- 
brane alone  was  not  painful.  He  likewise  claimed  that  cancer 
and  other  diseases,  while  restricted  to  the  mucous  membrane, 
produce  no  pain. 

The  pain  of  gastric  ulcer  can  generally  be  distinguished  be- 
cause of  its  several  characteristics,  as  follows : 

(1)  Time  of  Onset. — Pain  generally  begins  immediately  on 
the  entrance  of  food  into  the  stomach,  and  gradually  increases 
until  it  reaches  a  climax  (at  the  time  the  pyloric  end  is  at  work), 
and  then,  as  the  stomach  empties  itself,  it  becomes  less  and  less, 
and  gradually  disappears.  It  is  also  relieved  by  vomiting,  and 
in  many  cases  by  the  ingestion  of  alkalies.  After  an  hour  or  two 
it  ceases.  The  longer  the  interval  between  the  time  of  ingestion 
of  food  and  the  appearance  of  the  pain,  the  farther  away  from 
the  cardia  and  the  nearer  to  the  pylorus  is  the  ulcer.  If  it  has 
occurred  immediately  after  eating,  the  ulcer  is  probably  near 
the  cardiac  orifice  or  the  lesser  curvature ;  if  two  or  three  hours 
after,  it  will  be  at  the  pylorus;  and,  if  four  hours  after,  and 
relief  ensues  on  taking  food,  the  ulcer  is  probably  in  the  duo- 
denum. 

(2)  Character. — The  pain,  as  a  rule,  is  of  a  dull,  boring  char- 
acter, and  is  generally  localized  to  a  small  area  in  the  epigastrium. 
It  may  radiate  to  the  back.  Sometimes,  instead  of  a  pain,  there 
is  present  in  the  epigastrium  a  dull,  disagreeable,  constant  sensa- 
tion. When  this  is  present,  adhesions,  peritonitis,  and  increased 
continuous  secretion  of  gastric  juices  are  likely  to  be  found.  The 
statement  that  the  ulcer  can  be  mapped  out  by  percussion  is  mani- 
festly absurd,  as  can  readily  be  understood  from  a  study  of  the 
origin  and  propagation  of  gastric  pain.  A  peculiarity  worth 
noting  is  that  the  pain  is  most  severe  when  the  ulcer  is  located 
on  the  posterior  surface,  because,  in  this  location,  it  is  nearer  to 
the  parietal  peritoneum,  upon  which  there  is  more  drag  than 
would  occur  if  the  ulcer  was  situated  upon  the  anterior  surface. 
In  some  cases  there  may  be  a  burning  sensation  after  eating,  and 
the  pain  may  radiate  to  the  sides  of  tlie  chest  and  shoulder.  The 
sensation  varies  from  a  feeling  of  distress,  that  is  hardly  notice- 


LESIONS    OF    STOMACH    CAUSING    PAIN  445 

able,  to  a  pain  of  the  gi*eatest  severity.  This  pain  has  been 
described  as  cutting,  gnawing,  piercing,  or  burning. 

The  pain  of  pyloric  ulcer  is,  as  a  rule,  greater  than  that  of 
cardiac  ulcer. 

A  very  strong  reason  why  this  should  be  so  is  that  the  pylorus 
is  relatively  a  fixed  portion  of  the  stomach,  and  in  distention  or 
contraction  of  the  stomach  it  does  not  change  its  position  according 
to  the  change  in  the  position  of  the  remainder  of  the  stomach,  con- 
sequently pull  is  made  upon  it,  and  it  is  this  pull  upon  the  already 
irritated  structures  that  causes  pain.  This  pain  seems  to  occur 
most  frequently  in  the  mid-hours  of  the  night.  In  some  cases  psy- 
chical disturbance,  as  anger  or  great  emotion,  seems  to  be  conducive 
to  its  onset. 

(3)  Tenderness. — In  gastric  ulcer,  the  tenderness  which  is 
in  the  epigastrium,  in  many  cases  to  the  right  of  the  median 
line,  may,  because  of  adhesions,  be  localized  in  other  parts  of  the 
abdomen.  Ulcer  of  the  stomach  differs  from  gall-stone  and  all 
other  colics,  in  that  the  patient  is  very  sensitive  in  the  upper 
abdomen,  so  that  in  many  cases  he  will  not  bear  even  the  slightest 
pressure,  which  is  exactly  the  opposite  to  what  occurs  in  colic,  for 
here  pressure  seems  to  give  relief.  The  tenderness  to  palpation 
and  percussion  associated  with  ulcer  seems  to  vary  according  to 
the  degree  of  distention  of  the  organ — the  greater  the  distention 
the  more  severe  the  associated  pain. 

The  tenderness  elicited  on  palpation  is  of  two  types,  super- 
ficial and  deep.  The  superficial  tenderness  is  merely  an  expres- 
sion of  the  hypersensibility  of  the  skin,  while  the  deep  tenderness 
expresses  the  hypersensibility  of  the  muscles,  subserous  perito- 
neum, and  the  peritoneum  (parietal)  in  immediate  association 
with  the  ulcer.  When  the  tenderness  is  due  to  a  hypersensibility 
of  the  rectus  muscle,  it  will  be  found  that  the  muscle  is  in  a  state  of 
contraction,  and  that  this  contraction  is  localized  to  the  upper 
segment.  The  contraction  is  more  marked,  generally,  on  the 
right  side  than  on  the  left.  This  localized  contraction,  the  so- 
called  visceromotor  reflex  of  Mackenzie,  has,  in  some  cases,  been 
mistaken  for  a  tumor.     Sometimes,  if  the  patient  is  very  stout,  io 


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LESIONS    OF    STOMACH    CAUSING   PAIN  447 

is  difficult  with  ordinary  palpation  to  elicit  pain  in  the  rectus.  It 
then  becomes  necessary  to  make  very  firm  pressure,  with  the  abdo- 
men as  relaxed  as  possible,  so  that  the  area  of  tenderness  may  be 
defined.  After  having  examined  the  abdomen  it  is  well  to  examine 
the  back.  Here  a  tender  area  to  the  left  of  the  tenth,  eleventh,  or 
twelfth  dorsal  vertebrae  may  be  present.  Percussion  is  frequently 
used  to  exactly  define  the  area  of  tenderness.  The  lymphatics 
from  the  pylorus  are  in  association  with  the  upper  abdominal 
wall  on  the  right  side,  wdiile  the  lymphatics  from  the  cardiac  end 
of  the  stomach  are  distributed  to  the  upper  abdominal  wall  on 
the  left  side.  Since  ulcer  is  most  common  at  the  pyloric  end  of 
the  stomach,  this  will  account  for  greater  frequency  of  increased 
rigidity  of  the  right  rectus. 

(4)  Diet. — Foods  causing  the  production  of  pain,  or  increas- 
ing the  pain  already  present,  are  those  which  are  of  an  irritating 
nature  or  are  difficult  to  digest.  Of  the  first,  are  corn,  crusts  of 
bread,  some  breakfast  foods,  as  grape-nuts,  cherries  which  have 
been  swallowed  with  their  pits,  etc.  In  the  second  class,  pork, 
fresh  baked  bread  and  hot  rolls,  boiled  cabbage,  cucumbers, 
unripe  fruits,  strongly  spiced  foods,  the  various  salads,  and  pota- 
toes may  be  included.  Of  the  liquids  causing  an  increase  of  ulcer 
pain,  are  those  which  are  highly  acid,  or  those  which  contain  alco- 
hol, as  whiskey  and  beer.  In  many  cases,  also,  those  drinks 
which  in  themselves  are  stimulating  or  irritating,  as  coffee  and 
tea,  increase  the  pain.  Cold  drinks  likewise  sometimes  induce  a 
paroxysm  of  pain.  The  foods  which  are  well  borne  in  ulcer  are 
meats,  particularly  scraped  meat  (beef),  milk  with  lime  water, 
and  farinaceous  gruels.  Smoking  sometimes  seems  to  induce 
pain.  Possibly  this  is  a  result  of  a  stimulus  to  contraction  known 
to  be  caused  by  nicotin.  If  the  ulcer  is  situated  near  the  pylorus, 
and  the  stomach  is  adherent  to  the  pancreas,  the  pain  is  felt  most 
severely  in  the  intervals  of  gastric  digestion.  It  is  temporarily 
relieved  by  food  or  draughts  of  water. 

(5)  Change  of  Position. — If  the  pain  is  worse  in  certain  posi' 
tions  it  can  be  assumed  that  the  position  in  which  it  is  worst  is 
the  one  in  which  the  stomach  will  be  so  situated  that  pressure 


448  THE    STOMACH 

will  be  made  upon  the  ulcer  by  the  stomach  contents  and  abdomi- 
nal viscera.  A  change  of  position  will  also,  in  many  cases,  cause 
a  kinking  or  bending  of  the  jiylorus,  and  this,  in  turn,  produces 
traction  upon  the  ulcer-bearing  surface,  thus  causing  pain^ 

It  seems  to  be  the  rule  that  a  right  lateral  position  of  the 
body  is  most  painful  in  ulcer  of  the  pylorus.  The  opposite  seems 
to  be  true  in  cases  of  fundus  ulcer.  This  rule,  though,  is  true 
only  before  adhesions  have  formed.  After  their  formation  such  a 
change  of  position  of  the  body  that  the  stomach  will  have  a  tend- 
ency to  drop  away  from  and  pull  upon  the  adhesive  surface,  would 
cause  an  excess  of  pain  in  the  ulcer  and  adhesion  area.  In  all  cases 
the  pains  due  to  change  in  the  j)osition  of  the  body  are  increased 
at  the  time  of  the  spontaneous  attacks  common  to  ulcer.  In  many 
patients,  in  whom  the  ulcer  is  on  the  posterior  surface,  relief  is 
found  during  the  attack  by  lying  on  the  abdomen.  Lifting,  strain- 
ing, carrying  heavy  loads,  jumping,  and  rowing,  and,  in  some  cases, 
going  up  and  down  stairs,  excessive  respiratory  movement,  cough- 
ing and  sneezing,  running  and  walking  may  be  provocative  of  pain. 
During  attacks  the  patient  may  be  crouched,  the  lower  limbs  being 
flexed,  and  the  body  bent  forward.  He  may  lie  on  the  back  or 
abdomen,  or  on  either  one  or  the  other  side,  depending  upon  the 
location  of  the  ulcer. 

(6)  History. — Gastric  ulcer  generally  gives  a  history  of  at- 
tacks of  left-sided  pain,  which  may  or  may  not  be  a(?companied 
by  vomiting.  This  pain  gi-adually  passes  off,  and  the  patient  may 
be  free  for  several  weeks  or  months;  but  again  the  pain  comes 
on  and  lasts  a  little  longer  than  in  the  first  attack.  Thus  the 
pain  continues  to  come  and  go,  each  attack  being  of  briefer  dura- 
tion than  the  previous  one,  and  occurring  at  successively  shorter 
intervals. 

Conditions  accompanying  and  associated  with  gastric  ulcer 
are:  (1)  Vomiting,  which  comes  on  generally  after  the  ingestion 
of  food,  especially  if  the  food  be  of  an  irritating  kind.  It  occurs 
one-half  to  two  hours  after  eating,  but  may  take  place  almost 
immediately.  The  vomitus  of  an  ulcer  patient  is  somewhat  char- 
acteristic, in  that  it  often  contains  pure  blood. 


LESIONS    OF    STOMACH    CAUSING    PAIN  449 

(2)  ConstiiDation  is  frequently  present. 

(3)  Anemia  sometimes  occurs,  and  is  due  to  the  loss  of  blood 
in  the  vomitus  or  in  the  stools. 

(4)  Blood  is  sometimes  seen  in  the  stools  after  a  meat-free 
diet. 

(5)  Enteroptosis  frequently  accompanies  pyloric  ulcer.  In 
this  case  a  properly  adjusted  abdominal  supporter,  the  taking  on  of 
fat,  or  the  i^resence  of  pregnancy  frequently  eases  the  condition, 
the  cause  of  the  relief  in  the  latter  instance  being  due,  as  Schmidt 
suggests,  to  the  elevation  of  the  abdominal  viscera  by  the  rising  of 
the  enlarged  uterus. 

(6)  Pyrosis  or  regurgitation  of  sour-tasting  fluids  sometimes 
occurs. 

(7)  Belching  of  gas  and  tympanitis  are  common.  The  belch- 
ing of  gas,  with  the  accompanying  sour-tasting  eructations,  is 
almost  pathognomonic  of  gastric  ulcer. 

Perforating  Ulcers.- — The  perforation  of  a  gastric  ulcer  is 
one  of  the  tragedies  of  medicine.  It  is  ushered  in  with  pain 
(Eisendrath,  579),  which  is  severe  and  sudden,  and  of  an  intense, 
agonizing,  or  stabbing  character.  If  the  ulcer  is  on  the  anterior 
stomach  wall,  and  is  in  intimate  contact  with  the  anterior  abdom- 
inal wall,  the  pain  may  be  felt  at  first  around  the  navel.  In  either 
case,  as  the  associated  peritonitis  extends  down  into  the  right 
iliac  fossa,  it  rapidly  becomes  diffused.  The  original  pain  is  now 
accompanied  by  the  sharp,  intense  pain  that  is  so  characteristic 
of  a  spreading  peritonitis.  The  abdominal  muscles  become  rigid, 
and  marked  tenderness  develops  on  the  right  side.  A  complica- 
tion of  this  kind  can  be  diagnosed  from  appendicitis  in  that  the 
muscular  rigidity  in  appendicitis  is  more  markedly  localized  to 
the  right  iliac  fossa,  and  also  from  the  fact  that  in  gastric  ulcer 
there  is  often  a  history  of  hematemesis,  pain  after  eating,  and 
occult  blood  in  the  stools.  If  the  case  is  first  seen  several  hours 
after  perforation,  it  is  almost  impossible,  because  of  the  asso- 
ciated peritonitis,  to  diagnose  the  origin  of  the  pain. 

Diagnosis  of  Gastric  Ulcer. — The  pain  of  gastric  ulcer  dif- 
fers from  that  of  gall-stone  colic  in  the  following  ways : 


450  THE    STOMACH 

(1)  Pain  in  gall-stone  colic  is  paroxysmal,  and  lias  a  tendency 
to  radiate  over  the  right  side  to  the  right  scapula;  also  it  is  felt 
in  the  right  shoulder. 

(2)  Vomiting  nearly  always  relieves  the  pain  of  ulcer,  while 
it  may  have  no  noticeable  effect  on  gall-stone  colic.  In  ulcer  the 
vomitus  often  contains  blood.     In  gall-stone  colic  none  is  present. 

(3)  Local  anesthetics  and  mild  drinks  often  ease  the  pain  of 
ulcer.     They  would  have  no  effect  on  gall-bladder  colic. 

(4)  In  gall-stone  colic  there  is  frequently  a  history  of  pre- 
vious attacks,  with  an  accompanying  jaundice. 

Cholecystitic  pain  is  also  often  mistaken  for  ulcer  pain ;  but 
in  the  former  the  pain  is  constant,  and  the  enlarged  and  very  ten- 
der gall-bladder  can  be  felt.  Pain  of  hepatitis  has  sometimes  been 
confused  with  the  pain  of  gastric  ulcer,  but  in  the  former  there 
is  a  tenderness  beneath  the  right  costal  margin,  and  the  liver  is 
generally  enlarged. 

From  epigastric  hernia  gastric  ulcer  can  be  diagnosed  by  the 
physical  signs  of  the  hernia  which  are  present,  and  the  impulse 
on  coughing  and  straining.  Duodenal  ulcer  is  hard  to  distinguish, 
as  the  pain  symptoms  in  the  two  conditions  are  almost  identical, 
but  alypin  and  cocain  often  relieve  the  pain  of  gastric  ulcer, 
while  they  have  no  effect  on  that  due  to  ulcer  of  the  duodenum. 
To  distinguish  pyloric  from  duodenal  ulcer  Mennier  (66b)  has 
devised  the  following  test.  He  gives  the  patient  one  pint  of 
milk. 

In  Pyloric  Ulcer  In  Duodenal  Ulcer 

The    pain    is    relieved    after    a      The  pain  remains  with  the  same 
few  swallows,  and  gradually  intensity   for    5,    10,    or    15 

disappears.  minutes;    then     the     patient 

belches  gas,  and  suddenly  the 
pain  is  relieved.  This  re- 
lief is  synchronous  with  the 
opening  of  the  pylorus,  the 
belching  of  gas,  and  the  pas- 
sage of  the  stomach  contents 
into  the  duodenum. 


LESIONS    OF   STOMACH   CAUSING   PAIN  451 

Acute  pancreatitis  often  gives  rise  to  symptoms  similar  to 
those  of  gastric  ulcer;  but  here  there  are  generally  an  associated 
shock  and  collapse.  The  pulse  is  considerably  elevated,  and  a 
tumor  (enlarged  i^ancreas)  often  develops  and  lies  across  the 
upi3(ir  abdomen. 

Angina  pectoris  has  also  been  mistaken  for  ulcer-pain;  but 
the  associated  collapse  and  fear  of  impending  death,  the  presence 
of  unconsciousness,  and  the  radiation  of  the  pain  to  the  left 
shoulder  and  down  the  left  arm  make  the  diagnosis  easy.  In 
angina  pectoris  vomiting  does  not  occur,  and  diet,  as  a  rule,  has 
no  effect  on  the  incidence  of  the  pain;  but  exercise  and  violent 
emotion  seem  to  be  inciting  factors. 

Appendicitis  pain,  especially  if  it  occurs  in  the  region  of  the 
umbilicus  and  is  associated  v^^ith  vomiting,  has  frequently  been 
mistaken  for  that  due  to  gastric  lesions.  In  appendicitis  Morris's 
and  McBurney's  points  may  be  tender,  and  there  may  also  be  re- 
flected visceral  hyperalgesia  in  the  area  usually  associated  with  the 
appendix.  These,  with  the  absence  of  definite  symptoms  of  stom- 
ach involvement,  make  the  diagnosis  certain. 

Renal  colic  can  hardly  be  mistaken  for  gastric-ulcer  pain ; 
the  peculiar  radiation  of  its  pain  downward  and  inward  to  the 
pubes  makes  its  differentiation  somewhat  easy. 

The  pain  of  gastric  carcinoma  will  be  differentiated  when  it 
is  considered  a  few  pages  further  on. 

The  diagnosis  of  chronic  ulcer  of  the  stomach  is  easy,  and 
when  all  of  the  classical  symptoms  are  present  can  scarcely  occa- 
sion perplexity.  When,  however,  this  is  not  the  case,  it  may  be 
exceedingly  difficult,  or  even  impossible,  to  make  a  positive  diag- 
nosis. Important  diagnostic  factors  have  already  been  indicated. 
Two  other  diseases  of  the  stomach,  gastralgia,  or  gastrodynia  (as 
the  expression  of  functional  nervous  disturbance),  and  carcinoma 
resemble  the  symptom-picture  of  ulcer  when  ulcer  deviates  from 
its  typical  course.  It  seems  advisable  to  tabulate  their  important 
points  of  difference,  as  follows :  ^ 

*  Modified  from  ' '  Modern  Clinical  Medicine, ' '  Diseases  of  the  Digestive 
System,  page  188. 


452 


THE    STOMACH 


NERVOUS   GASTRALGIA 

ULCER 

CANCER 

Tongue  varies,  is  often  pale, 
and  fissured  at  the  borders 
or  upon  the  surface. 

Tongue,  dry,  red,  with 
white    streaks    in    the 
center,    or    is    smooth 
and  moist,  or  slightly 
coated. 

Tongue,  pale;  in  rare 
cases,  very  red,  dry. 

Frequent  eructation  of  odor- 
less gas. 

Eructations  either  rare, 
or  acid  with  pyrosis. 

Frequent  fetid  eructa- 
tions. 

Taste  unaltered,   dryness  of 
mouth  frequent;  sometimes 
salivation. 

Taste  unaltered. 

Pappy,  insipid  taste. 

Appetite  irregular,  capricious. 
Eating  brings  relief. 

Appetite  good  in  the  in- 
tervals;   thirst,    eating 
causes  pain. 

Appetite  decreased  or 
anorexia;  early  repug- 
nance to  meat;  eating 
causes  pain. 

Varying    sensations    in    the 
stomach,    sometimes    heat, 
sometimes  cold. 

Burning     sensation     in 
the  stomach.    Circum- 
scribed    boring     pain, 
often     radiating     pos- 
teriorly. 

Sensation  of  weight  in 
stomach ;  drawing 
pains  of  varying  char- 
acter, perhaps  pain  in 
the  shoulder. 

Spasmodic,  burning  pain,  in- 
dependent   of    food,    often 
ameliorated  by  the  latter  or 
by  pressure  upon  the  stom- 
ach.       Pressure  frequently 
eases  the  pain,  though  it  is 
common  for  the  anterior  ab- 
dominal wall   to  be  hyper- 
esthetic. 

Pains,     gnawing,     rare 
upon  an  empty  stom- 
ach, usually  appearing 
after    eating    or    upon 
motion  and  on  assum- 
ing positions  which  af- 
fect the  stomach;   in- 
creased upon  pressure. 
Pressure  points  (hyper- 
algesic)     upon     back. 
Pressure     over    abdo- 
men increases  the  pain. 
Sometimes  at  the  time 
of    paroxysms    it    will 
reheve  the  pain.      Pa- 
tients  sometimes   pre- 
sent the  chlorotic  type. 

Continuous  sensations 
of  dull  pain,  period- 
ically increasing  t  o 
paroxysms,  often  pro- 
duced by  pressure  or 
increased  by  it. 

Often  conjoined  with  hyster- 
ical symptoms.      Occurs  at 
all  ages,  more  frequently  in 
women  than  in  men. 

Most  frequent  in  middle 
life;   rare   in   children. 
Accompanied      by     a 
varying  psychical  con- 
dition, frequently  great 
depression. 

Most  frequent  between 
the  40th  and  60th 
years.  Psychical  con- 
dition that  of  depres- 
sion; melancholia,  but, 
strange  to  say,  less 
profound  than  in  se- 
vere cases  of  ulcer. 

LESIONS    OF    STOMACH    CAUSING   PAIN 


453 


NERVOUS  GASTRALGIA 


No  tumor  on  palpation,  un- 
less, as  rare  exceptions,  when 
foreign  bodies  (hair,  etc.) 
have  been  swallowed.  Chem- 
ism  varies;  absence  of  lactic 
acid. 


No  symptom  of  perforation 


Most  frequent  about  the  time 
of  the  menopause. 

History  of  nervous  disorders, 
as  neurasthenia,  hysteria, 
neuralgia,  etc. 


No  pain  between  attacks. 


Distention  of  stomach  pro- 
duces no  pain. 


When  the  ulcer  is  situ- 
ated at  the  pylorus 
with  consecutive  hy- 
pertrophy, an  ovoid, 
smooth  tumor  at  the 
right  of  the  median 
line  may  be  palpated; 
occasionally,  in  old  ul- 
cers with  a  hard  base 
and  callous  borders,  a 
palpable  circumscribed 
tumor  may  be  felt. 
Perforation  of  the 
ulcer  and  consequent 
adhesions  with  the 
head  of  the  pancreas 
the  left  lobe  of  the 
liver,  the  spleen  or 
the  omentum,  causes 
a  tumor  which  does 
not  move  with  the 
respiratory  excursion 
HCl  present  and  usu- 
ally increased. 


Perforation  into  neigh- 
boring organs  with 
characteristic  symp- 
toms may  occur  fre 
quently  after  apparent 
brief  duration  of  the 
disease,  even  occurring 
without  prodromes. 


Tumor  of  varying  size 
and  shape,  nodular  or 
smooth,  distinctly  pal- 
pable; as  a  rule,  pas- 
sively movable,  occas- 
ionally also  showing 
active  excursions  dur- 
ing respiration.  In  the 
majority  of  cases  ab- 
sence of  HCl ;  absence 
of  peptic  digestion  ;lac- 
t  i  c  acid,  lab-ferment 
sometimes  absent  (can- 
cer  of  the  pylorus), 
sometimes  present 
(cancer  of  the  fundus). 
Secondary  glandular 
enlargement ;  m  e  t  a  s- 
tases. 


Perforation  ;  implica- 
tions of  neighboring 
organs  only  after  pro- 
longed existence  of  the 
disease. 


Most  frequent  at  from 
15  to  35  years. 


History  of  anemia,  vom- 
iting of  blood,  dyspep- 
sia,   tuberculosis,    etc. 


Pain  attacks  may  be 
absent  for  years,  only 
to  become  again  mani- 
fest. 


Distention  produces 
most  severe  pain,  but 
it  is  a  very  dangerous 
procedure. 


Most   frequent   late   in 
life. 


History  of  cancer  in  fam- 
ily, also  of  a  gradually 
progressive  weakness. 


Attack,  when  it  comes 
on,  generally  lasts  till 
cancer  is  removed  or 
till   death   occurs. 


Distention  is  painful. 


454 


THE   STOMACH 


NERVOUS    GASTRALGIA 


Very  little  effect  on  general 
health. 


The  chemism  of  digestion  not 
especially  altered. 


Epigastric  pulsation.     Regu- 
lation of  diet  has  np  effect. 


Vomiting  irregular,  vomitus 
sometimes  contains  only 
mucus,  sometimes  more  or 
less  digested  stomach  con- 
tents, rarely  mixed  with  bile. 


No  hematemesis,  except  as 
accompaniment  of  very  rare 
complications. 


Almost  invariably  stubborn 
constipation;  normal  evacu- 
ations very  rare;  occasion- 
ally fluid  mucoid  dejecta,  the 
so-called  pseudo- diarrhea. 
Mucous  colic,  that  is,  colitis 
mucosa  membranacea. 


General   health   greatly 
affected. 


Digestion  of  starches  fre- 
quently slow;  that  of 
meat  normal,  or  even 
accelerated  ;  usually 
hyperchlorhydria. 


Alkalies   and    albumins 
ease  the  pain. 


Vomiting  as  a  rule,  im- 
mediately or  shortly 
after  eating,  and  fre- 
quently the  first  symp- 
tom of  the  disease; 
it  occurs  very  rarely 
without  the  taking  of 
food,  vomitus  hyper- 
acid. 


Vomiting  of  light  red 
blood  or  coffee-ground 
masses;  usually  re- 
peated in  a  brief  space 
of  time,  occasionally 
very  profuse,  followed 
by  extreme  anemia  and 
collapse;  compensation 
with  comparative  rap- 
idity; blood  in  the 
feces;  occult  hemor- 
rhages. 


Bowel  discharges  vary; 
not  infrequently  diar- 
rheal in  consequence  of 
intestinal  irritation  ; 
lientery  if  perforation 
of  the  ulcer  occurs  into' 
the  colon. 


General   health   greatly 
affected. 


Digestion  insufficient  ; 
usually  absence  of  free 
HCl;  and  the  forma- 
tion of  organic  prod- 
ucts of  decomposition. 


Epigastric  pulsation 
present  with  marked 
emaciation.  Regula- 
tion of  diet  has  no 
effect. 


Severe  and  frequent 
vomiting,  often  period- 
ic ;  occasionally,  also, 
before  the  ingestion  of 
food;  vomitus  is  mu- 
coid if  acidity  due  to 
the  presence  of  organic 
acids  is  present;  vom- 
itus shows  but  slight 
progress  of  digestion; 
sometimes  cancer  cells 
are  present.  Also  in 
some  cases  the  Boas- 
Oppler  bacillus. 


Decomposed  blood  more 
frequent  than  fresh; 
quantity  usually  small, 
but,  vomiting  having 
once  appeared,  it  re- 
curs frequently  at 
short  intervals. 


Almost  invariably  bow- 
els stubbornly  consti- 
pated; lientery  after 
perforation  of  the  ulcer 
into  the  colon. 


LESIONS    OF    STOMACH    CAUSING   PAIN 


455 


NERVOUS  GASTRALGIA 

ULCER 

CANCER 

No  fever. 

Mild  fever  with  adhe- 
sive inflammation  after 
rupture  of  the  ulcer, 
or  following  profuse 
hemorrhages. 

Fever  rare,  and  only 
towards  the  termina- 
tion of  life;  initial  {ever 
quite  rare. 

Skin  pale,  rarely  ruddy.    Skin 
of  normal  turgescence. 

Skin  usually  ruddy,  ap- 
pearance good,  anemic 
only  after  profuse  hem- 
orrhages; frequently 
the  pallor  is  visible 
in  the  mucous  mem- 
branes, and  even  in 
the  cheeks. 

Skin  sallow,  yellow- 
ish, dry,  and  flaccid; 
marked  cachexia. 

New  Growths  of  the  Stomach. — I^ew  growths  of  the  stomach 
cause  pain,  esjDecially  when  they  encroach  npon  the  pylorus  and 
thus  produce  a  partial  obstruction  with  a  consequent  gastric  dila- 
tation. Carcinoma  causes  pain,  particularly  when  it  ulcerates, 
and  when  infection  takes  place,  which  gives  rise  to  lymphangitis. 
According  to  Eisendrath,  there  is,  in  gastric  carcinoma,  at  first 
only  a  heaviness  after  eating,  then  later  a  pain  of  a  dull,  gnawing 
character  referred  to  the  epigastrium.  There  is  also  a  marked 
local  tenderness.  In  carcinoma,  or  other  new  growths  of  the 
stomach,  generally  there  are  in  some  stage  of  their  development 
characteristic  areas  of  cutaneous  hyperalgesia.  The  figaire  on  the 
next  page  illustrates  the  areas  mostly  involved. 

One  of  the  earliest  symptoms  of  carcinoma  is  the  feeling  of 
pressure  in  the  epigastrium,  occurring  a  short  time  after  eating. 
There  may  also  be  sensations  of  burning,  fulness,  or  of  epigastric 
tension.  When  the  pylorus  becomes  stenosed  the  pains  assume  a 
boring  or  twisting  character,  and  are  due  to  the  spasmodic  con- 
traction of  the  stomach,  which  is  attempting  to  force  its  contents 
through  the  narrowed  opening.  When  the  cancer  is  at  the  fundus, 
pain  is  present,  more  especially  when  the  stomach  is  full,  and 
may  radiate  towards  the  breast  and  back.  In  some  cases  it  is 
started  by  the  ingestion  of  food,  w^hile  in  others  it  is  produced  by 
mechanical  shock  or  by  change  of  position. 


456 


THE    STOMACH 


The  pain  in  gastric  carcinoma  may  vary  in  location,  depend- 
ing a  great  deal  uj^on  the  site  of  the  new  growth.  It*  seems  as 
though  the  nearer  the  growth  is  to  the  pyloric  end  of  the  stomach, 
the  farther  to  the  right  and  the  closer  to  the  umhilicus  will  he  the 
pain.     Sometimes  this  pain  radiates  around  the  sides  to  the  back. 


Areas  oi  ten- 
derness over 
6th,  7th,  8th 
dorsal  verte- 
bra 


Fig.  97. — Hyperalgesic  Zones  in  Cancer  at  Cardiac  End  of  Stomach. 

and  rests  between  the  shoulders,  or  runs  anteriorly  up  under  the 
lower  part  of  the  sternum;  or  it  may  radiate  backward  into 
the  iliac  regions.  The  reason  for  this  is  not  clear.  The  appear- 
ance of  pain  on  the  back  seems  to  be  favored  by  constipation 
(Schmidt)  ;  it  is  relieved  by  purgation.  Pain  is  also  frequently 
present  in  the  supraclavicular  region  on  the  left  side. 

The  pain  in  gastric  carcinoma  is  greatly  increased  when  in- 
fection takes  place,  and  a  perigastric  peritonitis  results.  The 
local  tenderness  is  also  much  increased,  and  extends  over  a  wider 
area.  Creaking  sounds,  due  to  the  movement  of  the  inflamed  peri- 
toneal surfaces  over  each  other,  may  be  heard  on  auscultation,  or 
be  felt  on  palpation.  The  pain  is  constant ;  and  is  increased  on 
the  taking  of  food.  Carcinoma,  although  having  a  resemblance 
to  gastric  ulcer,  should  be  distinguished  in  diagnosis.  In  gastric 
ulcer  pain  comes  on  immediately  after  the  ingestion  of  food ;  no 
tumor  mass  is  found ;  a  localized  area  of  extreme  tenderness  is 
present  in  the  epigastrium;  and  the  stomach  contents  yield  an 


LESIONS    OF    STOMACH    CAUSING    PAIN  457 

excess  of  hydrochloric  acid  with  the  absence  of  sarciuse  and  lactic 
acid.  The  exact  opposite  of  these  conditions  prevails  in  gastric 
carcinoma.  In  gastric  nicer  the  pain  generally  occurs  in  attacks 
at  irregular  intervals,  and  frequently  a  coffee-ground  vomitus  is 
present,  while  in  carcinoma  the  pain  is  more  continuous,  and  coffee- 
ground  vomit  is,  as  a  rule,  absent.  In  gastric  ulcer  the  ingestion 
of  food  increases  the  pain,  while  in  gastric  carcinoma  this  is  less 
liable  to  occur.  In  some  cases  of  carcinoma,  in  which  ulceration 
has  occurred,  the  pain  has  a  character  similar  to  that  of  gastric 
ulcer. 

The  posture  of  the  patient  generally  plays  but  a  minor  role 
in  the  production  of  pain  in  gastric  carcinoma,  though  the  pain 
is  worse  in  that  position  in  which  there  is  an  excess  of  pressure 
upon  the  carcinomatous  mass,  or  in  which  an  abnormal  degree  of 
traction  is  exerted  upon  the  surrounding  tissues.  Generally,  since 
the  carcinoma  is  most  frequent  at  the  pyloric  end  of  the  stomach, 
lying  upon  the  right  side  is  more  painful  than  lying  on  the  left. 
In  case  adhesions  have  formed,  change  from  one  position  to  an- 
other may  be  very  painful.  Rapid  changes  of  position  are  gen- 
erally productive  of  pain,  because  of  the  sudden  movement  of 
the  tumor  mass  from  one  place  to  another. 

It  is  claimed  that  benign  stenosis  of  the  pylorus  is  much  more 
painful  than  is  carcinomatous  stenosis,  because  in  carcinomatous 
stenosis  the  joatients  early  lose  their  appetite,  and  there  is  no 
great  mass  of  irritating  food  clamoring  for  passage,  as  in  a  be- 
nign pyloric  stenosis.  Also,  owing  to  carcinomatous  invasion  and 
lack  of  nutrition,  the  musculature  of  the  stomach  in  carcinoma 
soon  becomes  weakened,  and  is  unable  to  exert  as  great  a  propul- 
sive force  upon  the  contained  food  mass  as  in  pyloric  stenosis. 
These  conditions  are  present  only  late  in  carcinoma ;  early  in  the 
disease,  the  diet  being  the  same  as  in  benign  stenosis,  the  pains  of 
carcinoma  may  closely  resemble  those  of  the  latter.  Sometimes  in 
carcinomatous  pyloric  stenosis  the  colicky  pains  may  come  on  sev- 
eral hours  after  eating.  They  are  common  about  one  or  two  o'clock 
in  the  morning.    In  this  respect  carcinoma  resembles  gastric  ulcer. 

The  pain  in  gastric  carcinoma  is  due  to: 


458  THE    STOMACH 

(1)  The  Local  Disease. — In  gastric  carcinoma,  although  hy- 
drochloric acid  is  not  present,  other  organic  acids,  such  as  lactic 
acid,  etc.,  are  formed,  and  these  give  rise  to  excessive  peristalsis. 
When  the  growth  is  at  the  j^ylorus,  evacuation  of  the  stomach  is 
hindered,  and  pain  results  from  tension  of  that  part  of  the 
stomach  which  lies  between  the  pylorus  and  the  advancing  peris- 
taltic wave.  Should  ulceration  occur,  the  fine  nerve  endiugs  are 
exposed  in  the  bed  of  the  ulcer,  and  are  irritated  by  the  excessive 
amount  of  organic  acids  which  are  present  in  the  stomach.  This 
irritation  reflexly  causes  an  increased  peristalsis  and  very  severe 
pain.  In  the  latter  case  the  modus  operandi  of  pain  production 
is  exactly  as  in  ulcer.  Mansell  Moullin,  while  he  recognizes  the 
increase  in  joeristalsis,  however  thinks  that  the  pain  of  carcinoma 
is  due  to  a  hyperemia  of  the  peritoneum,  which  causes  it  to  become 
more  sensitive  and  to  react  to  peristaltic  traction  by  pain  produc- 
tion. 

(2)  Lymphangitis. — This  is  very  frequent  in  gastric  car- 
cinoma, and,  according  to  Lennander  and  others,  is  the  cause  of 
the  pain  felt  in  this  condition.  They  hold  that  the  inflammation 
progresses  into  the  mesogastrium  until  it  reaches  an  area  where 
cerebrospinal  nerves  are  encountered  and  are  irritated,  and  pain 
is  produced.  I^aturally,  when  the  inflammation  is  extending 
backward  along  the  lymph  j^aths,  the  lymph  glands  would  be  in- 
volved and  become  larger.  Pressure  may  then  be  exerted  upon 
adjacent  nerves  and  give  rise  to  pain.  Thus,  the  pain,  radiating 
around  the  chest  wall,  may  be  caused  by  pressure  on  the  intercos- 
tal nerves  from  the  enlarged  glands  of  the  prevertebral  area. 

(3)  Metastases. — Metastatic  growths  undoubtedly  cause  many 
of  the  radiating  pains  of  gastric  carcinoma.  Metastasis  may 
either  precede  or  follow  the  inflammatory  swelling  of  the  pre- 
vertebral lymph  glands,  and  alone,  or  in  association  with  it,  give 
rise  to  the  radiating  chest  and  abdominal  pains.  The  left  shoul- 
der pain,  so  often  complained  of  by  the  patient  with  gastric  car- 
cinoma, may  be  due  to  pressure  on  the  acromial  nerve  by  the 
enlarged  lymph  gland  or  glands  in  the  supraclavicular  region. 

Diagnostic  symptoms  associated  with  cancer  of  the  stomach 


LESIONS    OF   STOMACH    CAUSING   PAIN  459 

are :  in  the  early  stages  a  simple  regurgitation  of  sour  fluids ; 
in  later  stages  the  regurgitation  is  changed  to  a  vomit,  and  the 
fluid  is  of  gTeater  quantity,  often  fermented,  and  sometimes  con- 
tains blood  and  the  Boas-Oppler  bacillus.  If  the  cancer  is  well 
advanced,  a  definite  tumor  frequently  can  be  located  in  the  epi- 
gastrium. This  tumor  moves  with  respiration,  and  is  tender  to 
the  touch.  In  malignant  disease  of  the  pylorus  bile  may  be  present 
in  the  vomitus.  This  may  be  accounted  for  by  the  lack  of  tone  in 
the  jjyloric  sphincter,  due  to  the  atonic  condition  of  the  muscula- 
ture. The  ingestion  of  food  almost  immediately  starts  the  pain, 
which  generally  persists  until  the  stomach  is  relieved  of  its  con- 
tents by  vomiting  or  by  exit  through  the  pylorus.  The  kind  of  diet 
influences  the  severity  of  the  pain.  Indigestible  substances  or  those 
hard  to  digest,  as  cabbage,  corn,  pork,  tough  meat,  and  rye  bread, 
generally  are  productive  of  great  pain.  Left-sided  pleurisy  is 
often  associated  with  gastric  carcinoma,  and  frequently  gives  rise 
to  chest  pains. 

Pains  due  to  metastases  in  other  organs  may  follow  upon 
a  train  of  symptoms  indicative  of  gastric  carcinoma ;  these  pains 
are  most  frequently  located  in  the  epigastrium,  and  are  not  in- 
fluenced by  the  ingestion  of  food. 

Schmidt  claims  that  in  many  cases  of  tuberculosis  with 
dyspepsia  the  symptoms  could  be  confused  Avith  those  of  gastric 
carcinoma,  because  of  the  loss  of  weight,  anorexia,  and  epigastric 
pain  due  to  coughing. 

Perigastric  Adhesions. — In  case  of  long-continued  inflamma- 
tion and  lymphangitis  of  the  stomach,  such  as  result  from  gas- 
tritis or  from  ulcer,  the  pain  which  is  present  is,  in  almost  all 
cases,  due  to  the  adhesions  which  join  the  stomach  to  the  adjacent 
viscera.  Adhesions  existing  between  the  anterior  gastric  wall,  or 
pylorus,  and  the  parietal  peritoneum  are  the  most  painful.  A 
factor  of  importance  in  the  diagTiosis  of  gastric-adhesion  pain  is 
that  the  pain  is  made  worse  by  change  of  position,  though  in  the 
change  of  position  the  location  of  the  pain  remains  the  same. 
Another  factor  is  that  it  is  worse  during  active  peristalsis  or  dis- 
tention of  the  stomach,  and  is  always  located  in  the  same  area. 


460  THE    STOMACH 

Palpation  of  the  abdominal  wall  and  stomach,  as  a  means  of 
localizing  the  lesions,  is  useful,  for  if  adhesions  are  present  pres- 
sure made  in  an  upward  direction  from  the  lower  border  of  the 
stomach  will  increase  the  pain.  If  the  adhesions  are  to  the  right 
or  are  on  the  anterior  border,  pressure  made  over  the  epigastrium 


Area  of  pain  in  gastric  ulcer 

.  _,_  Area  of  pain  in  present  case 
.  _  _  Outline  of  stomach 


Fig,  98. — Point  of  Tenderness  and  the  Area  of  Pain  in  a  Case  of 
Perigastric  Adhesions. 

will  cause  pain  to  shoot  out  from  the  right  over  the  border  of  the 
stomach.  If  the  adhesions  are  on  the  posterior  gastric  wall  pres- 
sure over  the  first  and  second  lumbar  vertebrae  will  often  cause 
pain.  When  the  adhesions  are  between  the  anterior  abdominal 
wall  and  the  stomach  they  are  very  apt  to  be  confused  with  gastric 
ulcer  (Cumston,  580).  Erdman  (581)  claims  that  in  gastric 
adhesions  no  pain  is  complained  of  on  any  movement  of  the 
stomach,  only  a  sense  of  soreness  being  present.  This  is  contrary 
to  the  opinion  of  the  majority  of  observers. 

W.  Langdon  Brown  (583)  describes  a  pain  situated  just  be- 
low the  costal  arch  and  a  little  to  the  left  of  the  middle  line. 
Its  onset  had  no  relationship  to  the  ingestion  of  food,  but  came 
on  as  soon  as  the  direct  posture  was  assumed.  On  operation  a 
firm  adhesion  to  the  anterior  abdominal  wall,  about  the  size  of  a 
half  crown,  was  found  midway  between  the  greater  and  lesser 
curvatures,  and  rather  nearer  the  cardiac  than  the  pj^loriq  orifice, 


REFERRED    PAINS    CONFUSED  461 

The  stomach  was  in  direct  contact  with  the  anterior  abdominal 
wall.  In  some  cases  adhesions  between  the  anterior  abdominal 
wall  and  the  anterior  wall  of  the  stomach  may  cause  snch  severe 
symptoms  that  the  ^^atient  is  nnable  to  assume  the  upright  posi- 
tion and  remains  bent  forward  (Gilbride,  582). 

The  following  points,  as  given  by  Brown,  are  indicative  of 
perigastric  adhesions : 

(1)  The  symptoms  have  not  infrequently  been  preceded  by 
those  which  are  more  characteristic  of  gastric  ulcer  or  of  gall-stone 
colic;  (2)  local  tenderness  is  very  frequent;  (3)  pain  is  greatly 
influenced  by  the  position  of  the  patient;  (4)  vomiting,  as  a  rule, 
is  not  present;  (5)  careful  dieting  does  not  seem  to  have  much 
influence  on  the  pain.  Pressure  over  the  last  two  dorsal  verte- 
brae and  the  first  and  second  lumbar  frequently  causes  pain  in 
adhesions  of  the  posterior  gastric  wall. 

REFERRED  PAINS  CONFUSED  WITH  THOSE  OF  GASTRIC 

ORIGIN 

After  a  consideration  of  the  direct  pains  of  gastric  origin  it 
is  necessary  to  consider  those  referred  and  reflected  pains  that  are 
so  often  confused  with  them.  These  pains  are  of  nervous  origin 
and  are  due  to  neuralgia  of  the  sympathetic  or  of  the  intercostals ; 
or  are  projected  pains  from  cord  lesions,  or  are  referred  or  reflected 
pains  from  lesions  in  organs  at  a  distance. 

IsTeuralgia  of  the  sympathetic  or  of  the  vagus,  which  supply 
the  stomach,  may  occur  just  the  same  as  does  neuralgia  of  other 
nerves  in  other  parts  of  the  body.  In  neuralgia  of  the  vagus 
nerve  the  pain  is  felt  in  the  area  of  distribution  of  the  sensory 
fibers  of  the  afi^ected  nerve,  or  is  reflected  through  communicating 
branches  into  the  distribution  area  of  the  sensory  part  of  related 
nerves.  In  involvement  of  the  sympathetic,  pain  is  not  felt  in  the 
area  of  distribution  of  the  sympathetic  fibers,  but  the  irritation 
is  referred  to  the  cord  and  thence  outward  into  the  distribution 
area  of  those  spinal  nerves  whose  cord-associated  neurons  have 
been  stimulated. 


462  THE    STOMACH 

This  neuralgic  condition  may  exist  in  either  one  of  the  gastric 
nerves,  nanielj,  the  vagi  and  the  sphmchnics.  Both  may  be  sub- 
ject to  disorders  causing  pain.  Schmidt  reports  a  case  of  vagus 
neuralgia  in  which  pressure  in  the  left  external  auditory  meatus, 
or  irritation  over  the  j)ainful  area  with  a  combination  of  oil  of 
mustard,  menthol,  and  liquid  petrolatum,  caused  the  pain  to  cease. 

The  pain  of  intercostal  neuralgia  is  often  confused  with  that 
arising  from  the  stomach,  but,  though  the  pain  may  be  present  in 
the  epigastrium,  the  diagnosis  is  easy  if  it  is  remembered  that  in 
intercostal  neuralgia  there  are  tender  points  in  the  corresponding 
intercostal  spaces,  one  or  two  inches  from  the  spine.  These  are 
absent  in  gastralgia.  The  pain  oi  intercostal  neuralgia  is  also  in- 
creased on  exposure  to  cold  and  to  draughts. 

Lesions  of  the  cord  are  often  mistaken  for  gastric  disorders 
because  of  the  projected  pain  which  they  occasion;  but  here  there 
is  an  absence  of  gastric  symptoms ;  the  pain  is  generally  bilateral, 
and  there  are  other  well-defined  symptoms  of  the  nervous  dis- 
order. It  is  claimed  by  Schmidt  that  gastric  crises  (tabes)  often 
have  a  tendency  to  a  left-sided  localization.  (Schmidt,  584,  p. 
101.) 

It  is  also  characteristic  of  tabes  that  at  the  time  of  the  epi- 
gastric pains,  or  crises,  there  is  almost  always  an  uninterrupted 
and  exceedingly  painful  vomiting.  The  vomit  consists  at  first  of 
food,  later  of  a  mucous  fluid  which  is  sometimes  mixed  with  bile 
or  tinged  with  blood.  This  is  'accompanied  by  marked  nausea  and 
vertigo,  as  well  as  by  cardialgic  pains,  which  at  times  reach  a 
terrible  degree  of  intensity.  These  attacks  may  appear  at  the 
very  beginning  of  the  disease. 

Referred  pains  to  the  epigastrium  are  often  due  to  the  ap- 
pendix, uterus,  ovaries,  gall-bladder,  in  some  cases,  to  aortic 
aneurysm,  the  23ancreas,  sjjleen,  even  umbilical  hernia,  and  Addi- 
son's disease. 


CHAPTER  XXIV 

INTESTINAL    PAIN 

GENERAL  CONSIDERATIONS 

The  value  of  pain  in  the  diagnosis  of  intestinal  lesions  is  of 
more  moment  than  is  apparent  from  a  cursory  view  of  the  sub- 
ject. In  a  patient  in  Ayhose  case  the  diagnosis  is  obscure  the  cor- 
rect interpretation  of  the  pain  manifestation  is  of  vast  importance, 
and  may  be  the  means  of  eliciting  the  cause  of  otherwise  inex- 
plicable s^anptoms,  and  lead  to  effective  treatment. 

For  convenience  the  intestine  is  divided  into  two  portions, 
namely,  the  large  and  small,  both  of  which  are  united  to  the  body 
wall  by  a  mesentery.  The  mesentery  attached  to  the  large  bowel 
is  not  as  long  nor  as  mobile  as  that  attached  to  the  short  one,  so 
that  when  the  large  intestine  is  distended  beyond  its  normal  limit 
it  gives  rise  to  more  pain  than  does  a  proportionate  increase  in 
distention  of  the  small  intestine. 

Etiology  of  Pain. — The  researches  of  Mackenzie,  Lennander, 
and  well-known  anatomists,  physiologists,  and  surgeons  have 
shown  that  the  intestinal  mucosa,  of  itself,  is  insensitive  to  or- 
dinary forms  of  tactile  sensibility;  that  it  can  be  pinched, 
punched,  and  resected  without  producing  pain,  provided  no  trac- 
tion is  made  upon  the  mesentery  and  that  no  tension  is  exerted 
on  the  muscular  walls.  There  are,  therefore,  two  distinct  types 
of  intestinal  pain — possibly  more.  The  one  due  to  the  pull  and 
drag  upon  the  adjacent  peritoneal  structures;  the  other  a  true 
intestinal  pain  due  to  tension  within  the  muscular  structures. 
This  latter  type  of  pain — deep  sensibility  pain — has  often  been 
misinterpreted.      As   has  been   stated,   the   adequate   stimuli   for 

463 


464  INTESTINAL   PAIN 

visceral  pain  are  not  those  of  the  ordinary  tactile  or  thermal  types 
so  well  known  for  the  skin  and  niucons  surfaces.  The  adequate 
stimulus  here  is  tension  and  when  the  threshold  of  deep  pressure 
sensibility  is  reached  pain  results.  It  must  be  recalled  that  while 
tactile,  thermal,  chemical,  and  possibly  other  forms  of  stimuli 
may  not  be  capable  of  exciting  specific  receptors  in  the  intestinal 
canal,  nevertheless  they  are  capable  of  inducing  motor  reflex  ac- 
tivities causing  contraction,  and  that  contractions  which  cause 
tension  to  mount  to  the  deep  sensibility  threshold  result  in  pain. 
Deep  sensibility  sensations  may  be  transmitted  by  the  sympathetic 
fibers. 

However,  many  do  not  believe  that  pain  as  a  sensory  entity 
exists  in  the  intestine.  Since  these  hold  that  pain  is  not  present 
in  the  intestines,  they  must  be  asked  how  and  in  what  manner  it 
is  produced,  since  it  undoubtedly  is  felt  in  lesions  of  the  intestinal 
viscera.  It  was  formerly  held  that  pain,  as  pain  sensation,  is 
not  transmitted  by  sympathetic  fibers;  therefore,  the  only  nerve 
fibers  that  could  transmit  pain  directly  were  the  fibers  of  the  cere- 
brospinal system,  which,  except  the  vagus  (Bayliss  and  Starling), 
are  not  in  any  way  associated  directly  with  the  intestinal  viscera, 
although,  in  some  cases,  they  are  indirectly  associated  through  the 
phrenic,  the  lower  six  intercostals,  the  lumbar,  the  sacral  nerves, 
and  the  splanchnics  (Lennander).  The  sympathetic  cannot  carry 
stimuli  which  may  be  directly  interpreted  as  painful,  but  do  carry 
stimuli  which  are  reflected  to  the  body  wall  and  are  there  felt  as 
pain.  According  to  Lennander,  ''all  painful  sensations  within  the 
abdominal  cavity  are  transmitted  only  by  means  of  the  parietal 
peritoneum  and  its  subserous  layer,  both  of  which  are  richly  sup- 
plied with  cerebrospinal  nerves  around  the  whole  of  the  abdominal 
cavity,  possibly  with  the  exception  of  the  small  area  in  front  of 
the  vertebral  column,  lying  below  the  crura  of  the  diaphragm  and 
between  the  two  chains  of  sympathetic  nerves."  Here,  he  says,  as 
far  as  he  is  aware,  no  cerebrospinal  nerves  have  as  yet  been  demon- 
strated. On  a  few  occasions  he  has  observed  that  within  this  area 
the  patient  does  not  respond  to  hard  pressure  with  finger  or  instru- 
jnent^  nor,  furthermore,  does  he  experience  any  sensation  when 


GENERAL    CONSIDERATIONS  465 

a  small  portion  of  the  mesenteric  attachment  at  this  point  is  put 
on  the  stretch.  This  coincides  somewhat  closely  with  the  views 
of  Mackenzie,  that  it  is  only  the  snb-serons  peritoneal  layer  which 
is  the  cause  of  pain  in  intraabdominal  lesions.  However,  these 
elaborate  hypotheses  devised  by  Mackenzie  and  Lennander,  to  show 
why  pain  was  felt  in  intestinal  disorders  when  they  were  insensi- 
tive to  tactile  sensibility,  have  all  been  swept  away  by  the  recogni- 
tion of  the  fact  that  the  adequate  stimulus  for  intestinal  pain  pro- 
duction is  tension  and  not  the  well-known  pain-producing  stimuli, 
touch,  heat,  pressure,  etc.,  of  the  skin  and  the  mucous  membranes ; 
that  the  intestinal  j^ain  belongs  to  the  type  of  deep  sensibility  pain 
and  that  it  is  conveyed  through  the  sympathetic  nerve  fibers.  It 
had  been  held  for  a  long  time  that  the  sympathetic  nervous  system 
carried  no  pain  fibers.  Langley  and  Head  hold  the  contrary 
view.  In  any  case,  these  sensations  are  conveyed  to  the  cord, 
where  they  stimulate  certain  cord  segments,  and  thus  cause  pain  to 
be  referred  to  the  somatic  distribution  area  of  these  segments  or 
zones.^ 

That  pulling  and  stretching  of  the  mesentery  can  cause  pain 
is  shown  by  Lennander,  who,  in  describing  an  operation,  says  that 
"pain  was  occasioned  by  the  placing  or  removal  of  gauze  com- 
presses between  the  viscera  and  the  parietal  peritoneum,  by  the 
dragging  forward  of  the  cecum,  of  the  appendix  vermiformis, 
or  of  any  other  organ  whose  normal  attachment  to  the  anterior 
abdominal  wall  was  put  on  the  stretch."  The  same  principle 
applies  to  the  stretching  of  abdominal  adhesions,  which  may  con- 
nect the  viscera  with  the  anterior  abdominal  wall.  On  the  other 
hand,  should  a  compress  lie  between  the  viscera  without  coming 
into  contact  with  the  anterior  abdominal  wall  the  patient  experi- 

^  Wilms  (33b)  believes  that  only  the  spinal  nerves  can  convey  pain  sen- 
sation. He  says  that  the  intestine  of  man  has  no  sensory  nerves,  but  that  in 
the  mesentery  the  sensory  nerves  run  almost  to  the  intestines.  The  pain  in 
intestinal  colic  is  caused  by  a  pull  on  these  nerve  terminals  and,  therefore, 
the  pain  is  referred  to  the  area  where  the  mesenteiy  is  attached  to  the  ver- 
tebra— rather  that  the  pain  is  referred  out  along  the  peripheral  distribution 
of  the  spinal  nerves  connected  with  the  same  segment  of  the  cord  as  are  the 
nerves  from  the  mesentery,  so  that,  when  irritation  occurs  in  their  distribution 
area,  the  sensation  (pain)  is  referred  along  the  body  wall. 


3 

O  W 

CO  << 

H  CO 


fe  1-3 

O  < 

H  CO 

g  I 

W  l-H 


466 


GENERAL    CONSIDERATIONS 


467 


ences  no  sensation  when  it  is  removed.  Similarly  no  pain  at- 
tends the  stretching  or  breaking  up  of  adhesions  which  have  no 
connection  with  the  abdominal  parietes.  The  parietal  perito- 
neum along  the  thoracic  aperture  and  around  the  foramen  of 
Winslow  is  especially  sensitive  to  stretching  and  displacement. 
Robinson  (265)  reports  the  absence  of  cutaneous  hyperalgesia  in 
cases  of  acute  intestinal  obstruction. 


Pain  due  to  stomach 


Pain  due  to  small  intes- 
tine 


Pain,  enterocolonic 


Pain  due  to  large  intes- 
tine 


Pain  due  to  rectum  and 
sigmoid 


FiG.lOl. 


-Points  to  Which  Pain  Is  Referred  in  Lesions  of  Different 
Parts  of  Intestinal  Tract. 


The  pain  of  intestinal  origin  is  very  imperfectly  localized. 
The  reflex  hyperesthesia!  and  abdominal  projections  are  better 
capable  of  exact  localization.  They  are  therefore  of  great  prac- 
tical value. 

If  the  lesions  are  of  the  small  intestine  the  pain  is  reflected  to 
the  anterior  abdominal  wall  in  the  interval  between  the  umbilicus 
and  the  ensiform ;  if  the  disturbance  is  in  the  large  intestine  the 


468  INTESTINAL   PAIN 

pain  is  felt  slightly  below  the  umbilicus.  In  lesions  of  the  rec- 
tum and  sigmoid  it  is  felt  directly  above  the  pubes.  The  drawing 
on  the  previous  page,  according  to  Mackenzie,  shows  his  deductions. 

A  peculiarity  of  referred  somatic  pain  is  that  it  seldom  is  felt 
in  the  posterior  distribution  of  the  dorsal  segments,  but  is  almost 
invariably  present  in  the  anterior  distribution  area.  When  re- 
flected somatic  pain  is  present  in  the  posterior  distribution,  it  is 
always  present  at  the  same  time  in  the  anterior,  though  the  an- 
terior distribution  may  be  present  without  the  posterior  involve- 
ment. 

Wilson  (896)  advances  a  hypothesis  which,  because  of  its 
novelty,  is  quoted  here.  He  says:  ^'Muscle  fiber  has  two  oppos- 
ing types  of  activity:  (1)  the  contractile  activity,  due  to  contrac- 
tion of  the  longitudinal  elements  of  the  fibers;  and  (2)  the  ex- 
pansile activity,  due  to  contraction  of  the  transverse  elements  of 
the  fibers,  thus  causing  them  to  lengthen.  Some  pathological  ele- 
ments cause  the  bowel  to  expand  instead  of  contract,  so  that  there 
is  an  active  expansion."  He  thinks  that  the  rigid  arch  of  the 
abdomen  in  peritonitis  is  due  to  the  expansile  activity  of  the 
muscle  fibers  in  the  gut,  for  he  cannot  understand  how  a  contrac- 
tion of  the  abdominal  muscles  will  produce  an  arched  instead  of 
a  straight  line.  He  also  claims  that  in  some  cases  in  which  the 
irritation  causes  a  stimulation  of  the  expansile  activity  a  conflict 
takes  place  between  the  two  tendencies,  resulting  in  pain,  the  so- 
called  colic. 

Pain  may  also  be  referred  to  the  peripheral  distribution  of 
the  genitocrural,  the  ilioinguinal,  the  iliohypogastric,  the  exter- 
nal cutaneous,  and  the  accessory  nerve  to  the  external  cutaneous. 
In  these  cases  the  pain  is  due  to  pressure  made  upon  these  nerves 
by  increase  in  size  of  the  cecum  or  of  the  sigmoid.  It  is  very  fre- 
quent in  new  growths  of  these  organs. 

Besides  the  above  causes  of  pain,  due  to  intestinal  lesions,  we 
have  two  others  which  are  generally  forgotten,  or,  if  not  forgotten, 
are  thought  to  be  of  such  slight  importance  that  they  are  not 
mentioned.  These  are  the  pain  due  to  pressure  upon  adjacent 
nerves  by  lymphatic  gland  enlargement,  such  as  is  found  in  tuber- 


GENERAL    CONSIDERATIONS  469 

culous  intestinal  lesions  and  leukemia,  and,  second,  the  pain  due 
to  irritation  of  the  large  ganglia  of  the  sympathetic.  The  latter, 
either  by  direct  involvement  in  the  inflammatory  process  or  by 
irritation  from  stimuli  received  through  peripheral  branches, 
become  supersensitive  and  react  abnormally  to  normal  stimuli. 

By  many  observers  the  origin  of  the  epigastric  pain  which 
is  felt  in  so  many  intraabdominal  lesions  is  supposed  to  be  due 
to  an  irritation  of  the  solar  plexus.  This  is  undoubtedly  errone- 
ous, for  it  seems  that  the  solar  plexus  has  a  direct  connection 
with  pain  production,  only  in  so  far  as  it  acts  as  a  clearing  house 
for  stimuli  received  through  the  different  abdominal  sympathetic 
ganglia.  From  the  solar  plexus  are  derived  the  sympathetic 
fibers  which  connect  with  the  sixth  to  the  ninth  visceral  segments 
of  the  cord.  Irritation  to  these  fibers,  arising  either  independ- 
ently in  the  fibers  or  transmitted  from  the  ganglia,  is  carried  to 
the  cord,  whence  it  is  referred  to  the  body  wall  as  pain.  The 
maximum  point  of  tenderness  of  the  seventh  dorsal  segment  is  in 
the  epigastrium.  Since  it  is  generally  in  the  area  of  maximum 
tenderness  that  subjective  pain  is  felt,  it  is  in  this  area  that  pain 
associated  with  most  of  the  abdominal  lesions  is  perceived. 

Should  intestinal  disease  be  suspected  as  a  cause  of  abdominal 
pain  there  are  certain  characteristics  of  the  pain-symptoms  that 
lead  to  a  fairly  definite  decision,  not  only  as  to  the  involvement  of 
the  intestine,  but  even  to  the  segment  of  the  bowel  which  is  in- 
volved. The  characteristics  aiding  in  the  diagnosis  are  the  loca- 
tion of  the  pain,  its  type,  manijer  of  onset,  variation  (depending 
upon  the  position  of  patient),  duration,  result,  and  history  of  the 
pain,  and  the  associated  symptoms. 

Location  of  the  Pain.  — Nearly  all  painful  lesions  of  the  in- 
testine first  betoken  their  presence  by  circum-umbilical  pain.  In 
appendicitis  this  is  very  common,  but,  as  the  pathology  progresses, 
the  site  of  the  pain  is  changed  from  the  umbilical  region  to  the 
right  lower  quadrant  of  the  abdomen.  In  diseases  of  the  large 
intestine  the  pain  is  generally  felt  below  the  umbilicus,  while  in 
those  of  the  small  intestine  the  pain  is  generally  located  above.  A 
peculiar  characteristic,  and  one  that  is  of  great  value  in  diagnosis. 


470  INTESTINAL   PAIN 

is  that  in  diseases  of  the  large  bowel  pressure  on  the  abdomen,  over 
the  site  of  the  colon  (which,  in  its  transverse  division,  is  above  the 
umbilicus,  and  in  its  ascending  and  descending  divisions  to  either 
side  of  it),  will  produce  pain  in  the  mid-abdominal  zone  without, 
in  many  cases,  producing  any  pain  at  the  point  of  pressure.  In 
lesions  of  the  small  intestine  the  contrary  holds  true,  for  pressure 
in  the  area  below  the  umbilicus  generally  causes  pain  in  the  supra- 
umbilical  zone.  If  the  pain  that  is  felt  closely  resembles  that  pro- 
duced by  stomach  disorders,  as  is  so  often  the  case  in  duodenal 
ulcer,  and  an  examination  of  the  stomach  fails  to  reveal  any  abnor- 
mality, the  duodenum  should  then  be  suspected  as  the  cause  of  the 
pain.  It  is  very  common  for  the  duodenum,  because  of  its  close 
nervous  relationship  with  the  stomach,  to  produce  symptoms  sim- 
ilar to  those  of  gastric  disturbances.  In  some  cases  the  pain  of 
intestinal  disease  is  felt  in  the  back,  in  one  or  the  other  lumbar 
region.  Pain  in  the  back  generally  alternates  with  the  pain  of  the 
anterior  abdominal  w'all.    As  a  rule  both  are  not  coincident. 

Visceral  pain  depends  for  its  localization  largely  upon  the 
fixity  or  the  mobility  of  the  organ  affected.  The  more  fixed  the 
viscera,  as  a  rule,  the  more  constant  the  pain.  Thus  in  the  mobile 
and  freely  moving  small  intestine  the  localization  is  diffuse,  and 
centralizes  chiefly  about  the  umbilicus.  In  the  movable  parts  of 
the  colon  pain  is  felt  between  the  umbilicus  and  the  pubes.  In 
diseases  of  the  duodenum,  the  last  few  inches  of  the  ileum  and  the 
ascending  and  descending  colon,  and  in  lesions  at  the  hepatic, 
splenic,  and  pelvirectal  flexures  the  pain  is  felt  at  the  points  where 
these  structures  are  joined  to  the  abdominal  M'all. 

Type  of  the  Pain A  sudden  abdominal  pain,  associated  with 

vomiting,  should  always  suggest  an  acute  abdominal  lesion,  such 
as  an  obstruction  by  volvulus,  bands,  strangulated  hernia,  foreign 
body,  intussusception,  and  ajipendicitis.  If  the  vomiting  persists, 
and  the  pain  becomes  of  a  gradually  increasing  intensity  and 
spreads  over  a  wider  area,  it  is  certain  that  the  intestinal  lesion  is 
one  of  increasing  gi-avity.  At  the  same  time,  should  a  chill  and 
rise  of  temperature  accompany  or  precede  these  symptoms,  it  is 
very  likely  that  the  trouble  is  of  an  inflammatory  nature.     If  the 


GENERAL    CONSIDERATIONS  471 

pain  is  paroxysmal,  with  no  I'ise  of  temperature,  colic  should  be 
thought  of,  or  else  an  obstruction  should  be  sought.  Likewise,  if 
the  pain  is  of  a  griping  character,  and  is  accompanied  by  diar- 
rhea, enteritis  is  most  probable.  It  is  characteristic  of  patients 
whose  pain  is  due  to  lesions  of  the  lower  bowel  that  they  try  to 
ease  it  by  lying  with  the  back  bent  and  the  lower  limbs  flexed. 
In  case  the  pain  is  due  to  a  spasm  of  the  intestinal  muscles,  pres- 
sure and  heat  over  the  area  affected  will  often  give  relief.  If 
the  lesion  is  inflammatory,  heat  and  pressure  increase  the  pain, 
while  cold  often  produces  ease  and  comfort. 

Manner  of  Onset. — Intestinal  pain  may  be  gradual  or  sudden 
in  its  onset.  When  the  onset  is  gradual  with  a  slow  increase  in 
the  intensity,  we  know  that  the  lesion  is  gradually  increasing  in 
severity.  The  most  common  lesions  which  have  gradually  in- 
creasing pain  are  those  of  an  inflammatory  origin,  such  as  appen- 
dicitis, enteritis,  and  those  tuberculous  lesions  causing  peritoneal 
irritation,  especially  if  these  are  of  rapid  progress.  Should  the 
onset  be  sudden  it  generally  indicates  a  rather  severe  and  unusual 
derangement  of  the  intestinal  viscera,  such  as  may  occur  from 
knots,  kinks,  and  intussusception.  Generally  in  these  lesions,  and 
especially  in  all  lesions  which  produce  obstruction,  enlargement 
of  the  bowel  proximal  to  the  site  of  the  obstruction  occurs,  so 
that  palpation  of  the  abdomen  will  disclose  a  tumor  mass,  tym- 
panitic on  percussion.  If  in  a  case  of  acute  intestinal  pain,  tumor 
is  absent  and  palpation  reveals  an  area  of  exquisite  sensitiveness, 
gradually  increasing  in  extent,  it  frequently  is  an  indication  of 
a  perforation  of  the  bowel.  This  is  especially  true  in  those  who 
are  suffering  from  intestinal  tuberculosis  or  from  typhoid  fever. 
Should  the  pain  be  acute  in  onset,  and  be  relieved  by  vomiting,  it 
indicates  an  intestinal  spasm.  This  spasm  usually  is  caused  by  the 
collection  of  gas  due  to  fermentation  or  putrefaction  of  indi- 
gestible food,  and  often  is  followed  by  a  diarrhea  which  lasts 
for  a  day  or  two.  Should  acute  pain  occur,  followed  by  vom- 
iting which  finally  becomes  stercoraceous,  it  indicates  an  ob- 
struction which,  unless  relieved,  is  sure  to  cause  the  patient's 
death. 


472  INTESTINAL   PAIN 

In  those  obstructive  lesions  in  which  a  tumor  formation  is 
present  auscultation  reveals  exaggerated  peristalsis  over  the  tumor 
mass,  with  absent  peristalsis  below  it  in  the  area  where  the  intes- 
tines are  collapsed.  In  these  conditions  pain  is  also  very  com- 
mon after  eating,  coming  on  from  one  to  seven  hours  after  the 
ingestion  of  food.  Should  it  come  on  immediately  after  eating, 
it  is  due  to  the  stimulation  of  intestinal  peristalsis  by  the  en- 
trance of  food  into  the  stomacli. 

Relation  of  the  Position  of  the  Patient  to  the  Pain. — If  the 
pain  varies  in  intensity,  depending  upon  the  position  of  the 
joatient,  inilamnnitory  lesions,  either  acute  or  chronic,  should  be 
sought.  Change  of  i^osition  sometimes  causes  the  most  jDain,  espe- 
cially after  adhesions  have  formed.  The  pain  is  greatest  in  that 
position  in  which  the  abdominal  parietes  are  dragged  upon  by  the 
adherent  bowel,  and  is  always  localized  to  the  site  of  the  lesion. 
Colics  are  generally  indicated  by  great  restlessness  and  activity  of 
the  patient,  who  often  clasps  his  hands  over  the  abdomen  and 
exerts  pressure  upon  it;  on  the  contrary,  inflammatory  lesions  are 
generally  indicated  by  the  patient  assuming  a  position  in  which 
the  intraabdominal  pressure  is  lessened.  To  do  this,  he  lies  flat  on 
his  back  with  his  knees  drawn  up.  In  a  case  of  inguinal  or  fem- 
oral hernia  the  lower  limbs  are  flexed  and  at  the  same  time  rotated 
inward. 

Relation  of  the  Ingestion  of  Food  to  the  Pain. — There  are 
three  periods  in  which  after  the  ingestion  of  food  intestinal  pain 
occurs : 

(1)  The  first  period  follows  immediately  after  eating,  and 
lasts  for  a  varying  lenglh  of  time.  It  is  due  to  the  excitation  of 
intestinal  peristalsis  by  the  entrance  of  food  into  the  stomach, 
and  when  present  is  a  fairly  'good  indication  of  an  inflammatory 
lesion  in  the  bowel. 

(2)  The  second  comes  on  about  one  or  two  hours  after  eating, 
and  persists  for  a  couple  of  hours.  It  indicates  a  duodenal  in- 
volvement, often  an  ulcer,  or  perhaps  an  inflammation.  The 
two  hours  mark  the  duration  of  the  gastric  digestion,  and  time 
the  beginning  of  the  passage  of  the  food  from  the  stomach  into  the 


GENERAL    CONSIDERATIONS  473 

duodenum.  Pain  may  also  be  present  immediately  after  the  inges- 
tion of  food,  but  this  pain  only  persists  for  a  short  time,  and  is  then 
followed  by  the  duodenal  pain.  The  presence  of  adhesions  around 
the  duodenum,  following  common  duct  or  gall-bladder  disease, 
will  also  give  rise  to  this  type  of  pain. 

(3)  When  the  pain  is  delayed,  until  four  to  seven  hours  or 
longer  have  elapsed  after  the  ingestion  of  food,  it  is  a  sign  that 
the  trouble  is  low  in  the  bowel.  Appendiceal  pain  occurs  from 
four  to  seven  hours  after  eating,  and  is  very  prone  to  come  on 
about  midnight,  provided  the  evening  meal  is  taken  around 
six  or  seven  o'clock.  If  it  occurs  at  a  longer  interval  than  seven 
hours  it  is  an  indication  that  the  lesion  is  in  the  large  intestine. 
This  is  especially  true  if  rather  indigestible  foods,  as  stewed  cab- 
bage, etc.,  have  been  eaten. 

Duration  of  Pain. — A  pain  of  short  duration,  pathologically 
speaking,  is  generally  of  but  slight  moment,  while  one  of  long 
duration  indicates  a  lesion  of  more  or  less  severity.  The  more 
constant  the  pain,  and  the  greater  its  intensity,  the  more  should 
it  merit  our  attention,  not  only  because  of  the  portent  of  harm  to 
the  patient,  but  also  because  of  the  necessity  for  the  individual's 
ease  and  comfort  to  diagnose  and  relieve  the  symptoms  as  soon  as 
possible  after  examination  has  been  made  and  charge  of  the  case 
has  been  assumed. 

Result  and  History  of  the  Pain. — A  pain  that  passes  oif  with- 
out any  untoward  result  and  is  of  a  paroxysmal  type  generally  is 
due  to  colic.  If  the  pain  is  of  this  character,  the  different  colics, 
such  as  hernial,  foreign-body  colics,  volvular  colics,  and  those  due 
to  enteritis,  should  then  be  quickly  passed  in  mental  review.  Pan- 
creatic, biliary,  urinary,  and  uteripe  colic  also  should  not  be  for- 
gotten. If  there  be  a  history  cf  recurring  attacks,  associated  with 
vomiting  and  constipation,  especially  if  a  rise  of  temperature  and 
pulse  rate  is  present  at  the  time  of  the  attack,  and  tenderness  on 
the  right  side  is  marked,  appendicitis  should  be  suspected.  If  the 
attacks  are  spasmodic,  and  successively  shorter  intervals  occur 
between  each  successive  attack,  it  is,  in  case  of  ulcerative  lesion 
of  the  bowel,  an  indication  that  the  stenosis,  which  is  the  cause  of 


474  INTESTINAL   PAIN 

the  attacks,  is  progressing,  and  that  gradually  the  lumen  of  the 
bowel  is  becoming  more  constricted. 

Tenderness  is  of  two  types:  (a)  superficial,  and  (b)  deep. 
The  superficial  tenderness  often  exists  in  the  form  of  a  hyper- 
algesia. This  hyperalgesia  is  in  well-defined  zones,  which  have 
been  described  earlier  in  the  chapter.  Deep  tenderness  frequently 
is  present  over  the  area  of  the  bowel  involved,  and  is  due  to  local- 
ized peritoneal  inflammation.  When  pain  is  felt  at  the  site  of 
the  irritation  it  is  called  direct  pain  or  tenderness.  When  it  is 
felt  in  other  areas  it  is  called  indirect  pain  or  tenderness. 

In  the  diagnosis  of  intraabdominal  lesions,  especially  those 
of  the  alimentary  tract,  tenderness  may  be  of  much  importance. 
Where  the  tenderness  is  direct  it  is  due  to  inflammatory  irritation 
of  the  parietal  peritoneum  or  of  its  subserous  layer.  An  area  in 
which  direct  pain  is  present  is  tender  only  when,  on  palpation,  the 
pressure  exerted  is  strong  enough  to  irritate  the  peritoneal  sub- 
serous layer.  An  area  in  which  the  pain  is  indirect  (hyperal- 
gesia) is  painful  upon  the  slightest  irritation.  Even  the  drawing 
of  the  tip  of  the  finger  or  of  the  head  of  a  pin  across  the  surface 
is  extremely  painful.  This  very  marked  superficial  tenderness 
may  or  may  not  be  found  at  the  point  where  the  deep  mural 
tenderness,  or  tenderness  on  deep  pressure  would  indicate  the 
site  of  the  lesion. 

Symptoms  Associated  with  the  Pain. — Symptoms  associated 
with  intestinal  pain  are:  vomiting,  diarrhea,  tumor  (tympanitic 
or  dull  on  percussion),  tympany,  generalized  or  local,  obstipation, 
shock  and  collapse,  rise  or  fall  of  temperature,  changes  in  pulse  or 
respiration,  diaphragmatic  breathing,  and  inguinal  glandular  in- 
volvement. 

Vomiting  is  a  symptom  which,  in  obstructive  disorders  of  the 
intestine,  follows  shortly  after  the  initial  pain.  The  longer  it  is 
in  making  its  appearance  the  lower  is  the  lesion  in  the  bowel.  In 
nearly  all  intestinal  lesions  the  vomitus  consists  at  first  of  the 
contents  of  the  stomach,  then,  as  the  reversed  peristalsis  carries 
the  food  from  the  lower  segments  of  the  bowel,  it  becomes  more 
and  more  fecal  in  character.     From  the  time  of  the  onset  of  the 


GENERAL    CONSIDERATIONS  475 

vomiting  to  that  of  the  appearance  of  the  fecal  material  (if  the  ob- 
struction is  low  in  the  bowel),  a  fairly  good  estimate  of  the  location 
of  the  lesion  can  be  made. 

Diarrhea,  following  in  a  few  hours  the  onset  of  a  pain,  gener- 
ally indicates  an  enteritis,  the  pain  being  but  an  indication  of  the 
bowel  spasm  which  is  present.  Should  diarrhea  follow  at  a  consid- 
erable interval  after  the  beginning  of  the  attack,  it  is  likely  that 
obstruction  of  the  bowel  is  present,  and  has  progressed  to  such  an 
extent  that  j)eritonitis  has  been  produced.  It  must  be  remem- 
bered, however,  that  diarrhea  is  not  an  invariable  accompaniment 
of  enteric  obstruction,  constipation  being  present  in  all  cases  in 
the  early  stages,  and  often  persisting  until  the  end.  In  localized 
bowel  obstruction  there  is  present  a  tympanitic  tumor.  If  the 
tumor  is  in  the  center,  and  somewhat  to  the  left  of  the  median 
line,  it  indicates  that  the  lesion  is  probably  in  the  small  bowel; 
while  if  it  is  in  either  flank,  the  large  intestine  is  very  apt  to  be 
at  fault.  A  solid  tumor  associated  with  tympany  may  be  due 
either  to  tuberculosis  or  to  a  new  growth  (benign  or  malignant)  ; 
though,  generally,  neither  of  these  causes  any  severe  or  marked 
pain,  and  their  progress  is  gradual. 

Should  shock  and  collapse  be  associated  with  severe  abdominal 
pain,  it  may  indicate  the  rupture  of  the  intestine  into  the  abdomi- 
nal cavity.  The  rupture  may  be  due  to  previous  ulcer  formati<";i. 
either  typhoidal  or  tubercular.  TyiDhoid  perforation  occurs  most 
often  during  the  third  week  of  the  disease,  and  is  diagnosed  by  its 
characteristic  signs;  while  tubercular  intestinal  ulcers  betoken 
their  presence  by  special  symptoms.  Intussusception  and  volvulus 
are  frequently  associated  at  the  time  of  their  occurrence  with  con- 
siderable shock.  The  rupture  of  an  inflamed  appendix  causes 
great  shock,  and  generally  occurs  only  after  the  disease  has  been 
present  for  a  few  days.  Temperature,  pulse,  and  respiration  are 
of  value  in  the  diagnosis  of  tuberculosis,  typhoid  fever,  appendi- 
citis, and  strangulated  hernia.  They  are  but  slightly  changed  in 
volvulus  and  hernia.  Pain  on  deep  inspiration,  and  the  absence 
of  diaphragmatic  breathing  are  often  valuable  in  the  diagnosis  of 
peritonitis  originating  from  a  perforated  ulcer  or  a  ruptured  ap- 


476  INTESTINAL   PAIN 

pendix.     Glandular  enlargement  is  of  but  slight  diagnostic  impor- 
tance in  clearing  up  the  origin  and  cause  of  abdominal  pains. 

LESIONS  OF  THE  INTESTINES  CAUSING  PAIN 

Because  of  the  manner  of  origin  and  peculiarities,  intestinal 
neuralgia  and  colic  merit  a  separate  discussion.  The  lesions  of 
the  intestines  will  be  considered  in  the  following  order: 

(1)  Enteralgia. 

(2)  I^eurosis. 

(3)  Inflammation. 

(4)  Ulceration. 

(5)  Adhesions. 

(6)  Intestinal  obstruction. 

(7)  Diseases  of  special  parts  of  the  intestine,  such  as:  (a) 
appendix;  (&)  colon;  (c)  rectum;  {d)  anus. 

Enteralgia. — That  irritation  which  is  interpreted  as  painful 
may  of  itself  arise  in  the  intestinal  walls  without  an  associated 
inflammatory  state  is  very  likely.  Reasoning  from  analogy  the 
terminal  nerve  filaments  in  the  walls  should  be  subject  to  irritation 
by  toxic  substances.  This  irritation  sets  up  motor  activities  which 
are  interpreted  as  painful.  The  stimulus  (resultant  of  excessive 
motor  activity)  is  carried  by  the  sympathetic  nerves  to  the  cord, 
where  collaterals  of  the  spinal  nerves  are  involved.  This  causes 
reflex  hyperalgesia  in  the  abdominal  walls.  Yet  enteralgia,  as  a 
pathological  entity,  is  very  rare.  Pains  of  other  abdominal  lesions 
are  frequently  mistaken  for  bowel  pain,  and  the  intestine  is  cred- 
ited with  their  production,  when  it  has  no  association  with  them. 
Perhaps  even  more  frequently  organic  lesions  of  the  intestine  are 
mistaken  for  enteralgia.  How  many  times  appendiceal,  gall-duct, 
and  pancreatic-duct  colic  are  mistaken  for  it !  How  often  does  the 
patient  go  on  for  years  suffering  from  distressing  symptoms  asso- 
ciated with  these  disorders,  when  the  cause  could  have  been  so 
easily  removed,  and  the  individual  restored  to  comfort  and  hap- 
piness !     Schmidt,  who  quotes  from  Hawkins,  evidently  mistakes 


LESIONS    OF    THE   INTESTINES    CAUSING   PAIN        477 

other  lesions  for  enteralgia,  for  he  says  that  "the  pain  of  enter- 
algia  is  central,  occurs  in  short,  sharp  attacks,  quite  as  severe  as 
a  biliary  or  renal  colic,  and  is  equally  attended  with  sweating  and 
collapse."  An  analysis  of  the  above  should  convince  one  that  the 
pain  which  he  describes  as  enteralgic  may  be  nothing  more  than 
a  colic  of  the  intestine.  In  many  cases  the  reason  that 
the  generic  term  enteralgia  is  applied  to  abdominal  pain  colicky 
in  character  is  that  a  sufficiently  painstaking  observation  has  not 
been  made,  and  a  general  and  non-specific  term  has  been  applied 
to  hide  the  confusion  and  diagnostic  ignorance  of  the  examiner. 
Enteralgia  should  be  given  as  a  cause  of  pain  only  after  all  other 
causes  have  been  excluded ;  and  even  then  it  may  be  possible  that 
some  undiscovered  cause,  such  as  local  irritative  lesions  of  the 
musculature,  may  be  present.  Besides  the  myalgic  origin  enter- 
algia may  be  caused  by  some  such  similar  change  as  produces 
neuralgia  in  the  cerebrospinal  nerves,  and  we  have,  as  it  were,  a 
neuralgia  of  the  sympathetic.  When  a  probable  enteralgic  pain  is 
present,  without  any  apparent  lesion,  the  patient's  general  condi- 
tion should  be  carefully  studied,  to  find  out  if  any  of  the  disturb- 
ances which  are  known  to  produce  neuralgia  are  present.  If  they 
are  found  a  tentative  diagnosis  of  intestinal  neuralgia  may  be  made 
until  something  more  definite  is  discovered. 

Pain  Due  to  Functional  Disturbances. — The  functional  dis- 
turbances of  the  intestine  ^jroducing  pain  are  either  secretory  or 
motor. 

Secretokt  Disturbances. — That  it  is  possible  for  secretory 
derangement  of  the  intestine  to  cause  pain  cannot  be  disputed. 
The  disturbance  that  causes  the  most  pain  is  a  hyper-  not  a  hypo- 
secretion.  It  must  be  conceded,  however,  that  an  oversecretion  of 
intestinal  juices  cannot  of  itself  cause  pain,  unless  there  is  asso- 
ciated with  it  some  local  lesion  causing  either  an  inflammation  or 
a  circumscribed  spasm.  When  the  bowel  is  stimulated  on  its 
internal  surface  by  a  local  irritant  it  reacts  by  a  hypersecretion  of 
mucus.  This  mucus,  in  its  passage  down  the  bowel,  becomes 
rolled  into  balls,  or  else  adheres  to  the  intestinal  wall,  so  that  a 
greater  than  normal  contraction  of  the  musculature  of  the  intes- 


478  INTESTINAL    PAIN 

tine  is  necessary  to  force  it  on.  Tlins  spasm,  with  its  resulting 
pain,  is  produced.  It  is  not  known  whether  a  change  in  the  chemi- 
cal composition  of  the  intestinal  secretion  can  so  occur  that  the 
secretion  may  of  itself  become  irritating. 

Motor  Distuebances — ENTERosrASM.  —  Motor  disorders, 
such  as  spasm  of  the  intestine,  are  a  potent  cause  of  pain.  The 
spasms  are  due  to  some  local  irritative  lesion  in  the  bowels  or 
are  the  result  of  referred  stimuli.  The  local  cause  produces  a 
contraction,  restricted,  as  a  general  rule,  to  a  small  area  of  the 
bowel ;  while  the  contraction  spasm,  due  to  a  central  stimulation, 
may  extend  over  a  considerable  section  of  the  bowel.  These  re- 
ferred stimuli  may  result  from  some  disorder  of  the  sympathetic 
nerves  or  of  their  ganglia,  or  may  possibly  be  due  to  a  lesion  in  the 
cerebrospinal  system.  Such  causative  factors  are  found  in  neu- 
rasthenia, either  of  the  symj)athetic  or  of  the  cerebrospinal  type. 

The  local  lesions  causing  intestinal  spasm  are  most  frequently 
the  result  of  irritation  from  undigested  food,  irritative  poisons, 
and  foreign  bodies.  The  spasm  resulting  from  this  irritation 
gradually  progresses  downward,  following  in  its  course  the  descent 
of  the  irritating  substance.  Likewise  the  pain  gradually  moves 
from  the  epigastrium  down  over  the  anterior  abdominal  wall,  until 
it  becomes  localized  in  the  suprapubic  region.  In  other  cases 
the  irritation  may  be  localized  and  non-progTessive,  and  the  pain 
is  stationary.  When  such  a  condition  is  present  inflammation  or 
ulceration  is  most  commonly  the  cause. 

The  pain  of  enterospasm  is  divided  into  two  classes:  (a)  pri- 
mary and  (h)  secondary. 

(A)  The  primary  pain  is  due  to  two  causes:  (1)  the  pres- 
sure made  by  the  contracting  muscular  walls  upon  the  nerves  ter- 
minating between  the  muscle  bundles.  Lennander's  experiment 
on  the  intestine  with  electrical  stimuli,  which  caused  contraction 
and  no  pain,  is  non-conclusive,  as  the  adequate  stimulus  was  ab- 
sent, and  the  contraction  one  of  an  entirely  different  kind  than 
that  which  normally  is  present  in  the  intestines. 

(2)  The  pull  and  drag  exerted  upon  the  mesentery  by  irreg- 
ularities in  the  size  of  the  bowel. 


LESIONS    OF    THE   INTESTINES    CAUSING   PAIN        479 

(B)  Secondary  pain  is  due  to  distention  of  the  bowel  proxi- 
mal to  the  area  of  spasm.  It  is  of  the  ordinary,  colicky  type,  its 
duration  depending  upon  the  kind  and  manner  of  the  irritation. 
Should  the  irritation  be  of  a  transient  nature,  as  is  found  in  dis- 
turbances due  to  the  passage  of  indigestible  food,  the  pain  is  in- 
termittent and  varies  in  location,  though  it  constantly  progresses 
toward  the  lower  part  of  the  abdomen.  Should  the  lesion  be  or- 
ganic the  pain  is  permanently  localized  and  is  not  progressive,  but 
remains  at  the  point  related  to  the  bowel  proximal  to  the  point  at 
which  the  intestinal  distention  begins.  The  colon,  owing  to  its 
being  most  exposed  to  irritation,  is  most  frequently  the  part  of 
the  bowel  involved  in  the  spasm.  In  mucous  colitis  the  attack  is 
typical  (see  Colon). 

In  a  case  reported  by  Hawkins  and  quoted  by  Maylard  ^  a  good 
description  of  colon  spasm  is  given:  "In  this  patient  attacks 
came  on  once  in  about  three  or  four  years.  They  began  as  a  con- 
stipation, which  was  difficult  to  relieve;  distention  ensued,  and 
with  it  pain  and  vomiting.  The  pain  was  aggi'avated  by  the 
taking  of  food  and  by  defecation.  At  the  operation,  which  was 
performed  for  the  relief  of  this  condition,  two  areas  of  contrac- 
tion spasm,  without  any  associated  lesions,  were  found.  The  first 
was  at  the  junction  of  the  descending  colon  and  the  sigmoid  flex- 
ure. The  second  was  in  the  small  intestine.  Both  areas  showed 
a  spasm  of  the  musculature  of  such  magnitude  that  nothing  could 
be  passed  through  the  lumen  of  the  bowel.  In  both  the  narrowed 
part  of  the  bowel  passed  abruptly  into  the  normal  parts  above 
and  below." 

That  such  a  localized  spasm  occurs  is  known  to  every  practi- 
tioner of  medicine.  Many  and  many  a  patient  complains  of  fleet- 
ing, colicky,  abdominal  pain,  persisting  off  and  on  for  years. 
Operation,  should  it  be  undertaken,  reveals  conditions  somewhat 
like  those  described  above,  or  shows  nothing,  in  which  case  the 
appendix  is  often  blamed,  and  sometimes  rightly,  for  many  cases 
of  colic  owe  their  origin  to  a  fibroid  appendix.  This,  because  of 
its  constant  irritation,  produces  abnormal  excitability  to  stimuli 

*  Herbert  P.  Hawkins,  British  Medical  Journal,  January  13, 1906,  p.  65. 


480  INTESTINAL    PAIN 

in  the  sympathetic  nerves  and  plexuses  which  supply  it.  This 
excitability,  in  turn,  is  communicated  to  adjacent  centers  supply- 
ing the  small  intestine,  which  may  also  become  involved  and  be 
thrown  into  a  state  of  pathological  excitability.  When  they  are 
in  this  condition,  stimuli  that  ordinarily  would  produce  no  reac- 
tion may  cause  pain,  or  else  may  reflexly  produce  spasms  of  the 
bowel,  which  in  turn  cause  pain. 

In  some  cases,  because  of  generalized  abdominal  symptoms, 
enterospasm  has  been  diagnosed  as  peritonitis.  The  following, 
which  are  present  in  enterospasm  and  absent  in  peritonitis,  aid  in 
the  diagnosis:  (1)  The  low  temperature,  pulse,  and  respiratory 
rate;  (2)  the  excess  of  peristalsis,  even  though  the  abdomen  may 
be  rigid  and  tender;  and  (3)  the  absence  of  any  tendency  of  the 
process  to  increase  in  severity. 

The  intestine,  because  it  has  a  lumen  of  a  fairly  constant  size, 
is  subject  to  spasm-pain  throughout  its  entire  length.  Because  of 
the  progressive  nature  of  the  spasm,  the  pain  is  felt  at  diiferent 
points  on  the  abdominal  wall,  depending  upon  the  part  of  the 
intestine  which  is  involved. 

In  some  cases  spasmodic  musculature  contraction  of  the  small 
bowel  occurs  without  any  apparent  organic  cause,  and  is  due  to 
abnormal  functional  activity.  Those  who  are  subject  to  these 
spasms  are  so  sensitive  to  irritative  nervous  influences  of  any  kind 
that  the  slightest  change  from  the  normal  may  cause  a  spasmodic 
contraction  of  the  bowel.  This  change  also  may  be  the  result  of 
local  changes  (slight  fermentation)  in  the  intestine  (producing  a 
local  colic),  or  may  be  due  to  causes  acting  from  a  distance,  such  as 
exposure  to  cold  drafts,  which  produce  an  internal  congestion, 
etc.  During  bodily  fatigue  colic  is  also  felt.  The  bowel  contrac- 
tion in  the  latter  case  is  probably  due  to  the  irritation  from  the 
toxic  materials  circulating  in  the  blood.  Excessive  heat  may  abo 
act  in  the  same  manner. 

All  these  disorders  cause  a  derangement  of  intestinal  secre- 
tion, with  consequent  fermentation  and  putrefaction  of  the  intes- 
tinal contents.  These,  in  turn,  irritate  the  intestinal  mucosa,  and 
this  irritation  may,  in  some  cases,  progress  to  an  active  inflamma- 


LESIONS    OF    THE   INTESTINES    CAUSING   PAIN        481 

tion  of  the  bowel.  In  any  case  diarrhea  is  a  frequent  accompani- 
ment of  this  condition.  It  indicates  that  the  changes  in  the  mucosa 
and  bowel  contents  act  as  irritants  and  cause  an  excessive  contrac- 
tion and  forcible  propulsion  forward  of  the  bowel  contents.  How- 
ever, the  only  structure  particularly  affected  is  the  mucosa,  which 
at  the  time  is  in  a  state  of  weakened  resistance.  This  reduction  in 
resistance  is  often  caused  by  congestion  incidental  to  the  chilling 
of  the  body  surface,  in  which  a  peripheral  vasomotor  contraction 
occurs.     A  similar  vasomotor  spasm  may  also  be  caused  by  emo- 


Descending  colon, 
®    )      \  I      '•  sigmoid 

f  Appendix,    cecum, 
\  ascending  colon 

.J Transverse  coloii 


Fig.  102. — Pain  Areas  in  Colonic  Colic. 
Colonic  colic  begins  around  the  umbilicus  and  radiates  in  the  directions 
indicated.    The  pain  of  all  colics  of  the  colon  is  generally  referred  at  first 
around  the  umbiUcus  and  then  later  to  the  area  below  it.  However,  if  the 
lesion  is  in  the  small  bowel  the  pain  is  referred  above  this  level. 


tional  stress,  such  as  is  present  in  anger  and  extreme  joy  or 
dejection. 

Colics  may  be  the  result  of  some  definite  error  in  diet,  such 
as  the  eating  of  indigestible  or  bad  foods.  Many  persons  cannot 
indulge  in  whiskey,  eat  highly  spiced  foods,  nor  drink  very  cold 
or  unsuitable  liquids  without  suffering  from  colic.  People  vary 
somewhat  in  susceptibility,  so  that  what  one  person  can  do  or 
take  with  immunity    will  in  another  cause  colic. 

Since  these  attacks  of  colic  often  follow  a  slight  indiscretion 


432  INTESTINAL   PAIN 

in  diet,  possibly  such  an  indiscretion  as  has  occurred  many  times 
previously  without  the  production  of  colic,  the  patient  is  apt  to 
ask,  and  the  physician  himself  should  know,  the  reason  of  its 
greater  frequency  at  one  time  than  at  another.  Its  incidence  is 
probably  determined  by  a  lessened  resistance  due  to  changes  in 
atmospheric  conditions,  or  to  removal  from  one  locality  to  an- 
other, especially  among  those  who  are  not  accustomed  to  traveling. 
In  these  the  colic  is  probably  due  to  change  in  habits  and  diet. 
Constipation,  with  irregular  evacuation  and  overfeeding,  is  an- 
other cause  of  this  colic. 

The  most  reasonable  hypotheses  as  to  the  cause  of  colic  are 
those  promulgated  by  !Nothnagel,  Lennander,  and  Wilms.  Noth- 
nagel  says  that  colic  is  due  to  tetanic  contraction  of  intestinal 
muscles  and  the  anemia  produced  by  this  contraction.  Lennander 
claims  that  in  colic  in  the  small  intestine  the  pain  is  due  to 
pressure  against  the  sensitized  parietal  peritoneum  by  the  tetanicly 
contracted  loop  of  small  intestine,  and  that  pain  from  similar  peri- 
staltic action  of  the  large  intestine  is  due  to  traction  on  its  short 
mesentery.  On  the  other  hand,  Wilms  believes  that  colic  in  both 
the  large  and  small  intestines  is  due  to  traction  on  the  mesentery. 
The  simple  explanation  is  that  the  pain  of  colic  is  that  caused  by 
distention  of  the  muscular  walls.  It  is  a  special  type  of  pain 
conveyed  by  the  sympathetic. 

Colics  generally  are  sudden  in  onset.  The  pain  commences 
around  the  umbilicus,  and  thence  radiates  either  above  (small  in- 
testine) or  below  (large  intestine).  The  advance  of  the  intestinal 
spasm  is  often  indicated  by  changes  in  the  location  of  the  pain. 
When  the  spasm  is  in  the  small  intestine,  the  pain  is  above  the 
umbilicus;  when  in  the  jejunum,  cecum,  and  appendiceal  region, 
the  pain  is  around  the  umbilicus;  when  the  large  bowel  is  in- 
volved, the  pain  is  below  the  umbilicus,  and,  as  the  spasm  pro- 
gresses toward  the  rectum  and  anus,  the  pain  passes  do\\Ti  toward 
the  pubes,  and  becomes  lower  and  lower,  until  it  rests  just  above 
the  pubes,  which  is  a  sign  that  the  bowel  contents  have  reached  the 
sigmoid.  The  pain  now  remains  stationary  until  the  fecal  mass  is 
expelled. 


LESIONS    OF    THE   INTESTINES    CAUSING   PAIN        483 

At  the  time  when  the  colic  is  at  its  greatest  intensity  the  pain 
"may  be  so  severe  as  to  cause  the  patient  to  cry  aloud.  He  also 
is  very  restless,  moves  constantly  about,  throws  his  limbs  in  all 
directions,  and  often  lies  prone  upon  the  bed  or  upon  the  floor. 
Frequently  he  presses  a  pillow  or  his  hands  tightly  over  the 
abdomen.     This  seems  to  relieve  the  pain  (see  drawing). 

Type  of  Pain  in  Colic. — The  pain  may  be  either  intermittent 
or  constant.  When  intermittent,  it  becomes  lower  and  lower 
in  the  abdomen,  and  finally  ceases  on  the  expulsion  of  flatus  or 
feces.  Should  the  pain  be  constant,  it  shows  that  the  obstruction 
has  become  constant  and  persists  at  one  place.  An  obstruction  of 
this  kind  is  present  in  strangulated  hernia  and  intussusception. 
Intermittency  in  a  colicky  pain  shows  that  the  obstruction  has 
only  been  temporary.  Such  an  obstruction  may  be  produced  by 
kinks  in  the  bowel,  hardened  fecal  masses,  and  the  like.  Relief 
of  the  pain  indicates  that  the  obstruction  has  been  overcome.  An 
onward  movement  of  the  bowel  contents  follows,  and  frequently 
gives  rise  to  a  gurgling.  If  the  obstruction  becomes  permanent  a 
considerable  local  distention  takes  place  and  causes  tumor  forma- 
tion, excessive  proximal  peristalsis,  and  an  absence  of  gurgling 
over  the  tumor.  If  pain  persists  and  is  accompanied  by  diarrhea, 
vomiting,  and  abdominal  tenderness,  it  is  a  good  indication  that 
inflammatory  changes  have  taken  place. 

Tenderness  is  associated  with  enterospasm.  The  amount  of 
the  tenderness  depends  on  the  location  and  the  extent  of  the 
bowel  involvement.  It  seems  to  be  the  rule  that  disturbances  at 
either  extremity  of  the  small  or  large  intestine  give  rise  to  a 
greater  degTee  of  tenderness  than  do  those  of  the  middle  part. 
The  tenderness  may  be  indirect,  as  illustrated  in  involvement  of 
the  transverse  colon,  where  pressure  on  the  abdomen  above  the  um- 
bilicus in  the  region  of  the  colon  will  cause  pain  which  is  not  felt 
in  the  area  over  which  the  pressure  is  made,  but  in  the  anterior 
abdominal  wall  below  the  umbilicus.  If  the  small  intestine  is  in- 
volved, pressure  on  the  abdominal  wall,  particularly  kneading  of 
the  abdominal  contents,  will  produce  pain  in  the  epigastrium. 
Local  tenderness  over  the  site  of  a  bowel  lesion  is  unusual,  unless 


484  INTESTINAL   PAIN 

the  abdominal  wall  (parietal  peritoneum  and  subserous  layer)  is 
also  involved. 

Intestinal  colic  should  be  diagnosed  from  gall-stone,  renal, 
and  uterine  colic,  pyloric  spasm,  perforation  of  the  bowel,  appen- 
dicitis, acute  pancreatitis,  mesenteric  embolus,  and  thrombosis; 
from  the  referred  pains  due  to  thoracic  diseases,  as  pleurisy,  pneu- 
monia ;  and  also  from  the  abdominal  crises  occurring  in  certain 
diseases  of  the  nervous  system,  as  tabes,  etc. 

Should  colic  be  present  without  any  well-defined  bowel  lesion, 
particularly  if  it  occurs  in  a  painter  or  in  one  who  is  accustomed 
to  handle  considerable  quantities  of  white  lead,  it  is  well  to  find 
out  if  the  cramp  is  due  to  plumhism,  pathognomonic  signs  of 
which  are  stippling  in  the  red  blood  cells,  the  blue  line  on  the 
gums,  and  the  wrist  drop  and  foot  drop  (only  occasionally,  in  the 
early  cases),  or  other  signs  of  neuritis.  Contraction  and  rigidity 
of  the  abdominal  muscles  occur  at  the  same  time  as  the  colic.  In- 
equality of  the  pupils  and  tenderness  over  the  nape  of  the  neck 
are  also  to  be  noted. 

The  colicky  pain,  as  a  rule,  is  felt  in  the  center  of  the  abdo- 
men, in  the  umbilical  region.  The  sensation  is  that  of  the  intes- 
tine being  twisted.  Some  describe  it  as  a  feeling  in  which  it  seems 
as  though  the  bowels  were  being  tied  in  a  knot.  During  the  colic 
the  arterial  tension  is  raised  and  the  pulse  is  hard.  Pal  says  that 
the  pain  of  lead  colic  is  due  to  irritation  and  constriction  of  the 
blood  vessels  in  the  intestinal  walls,  and  that  this  indirectly  irri- 
tates the  sympathetic  nerve  filaments. 

There  is  also  a  colic  associated  with  ur'emia.  In  this  condi- 
tion, beyond  the  colic,  the  only  other  symptoms  are  those  of 
the  uremia. 

Inflammation  of  the  Bowel. — Inflammation  of  the  bowel,  as 
a  rule,  causes  little  pain  as  long  as  there  is  no  excess  of  motor 
activity.  When  active  peristalsis  occurs  there  is  a  well-defined 
pain ;  and  if  the  parietal  peritoneum  is  invaded  a  local  tenderness 
is  added  which,  as  a  rule,  is  confined  to  the  involved  area  of  the 
abdomen.  When  all  the  coats  of  the  bowel  are  involved  in  the 
inflammatory  process,  pain  is  also  reflected  to  the  anterior  abdomi- 


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485 


486  INTESTINAL   PAIN 

nal  wall,  and  hyperalgesia  is  i3reseiit  in  the  cord  zones  associated 
with  the  intestine. 

In  inflammatory  states  of  the  small  intestine  entrance  of  food 
into  the  stomach  may,  by  stimulating  and  increasing  the  peri- 
stalsis, aggravate  a  pain  already  joresent,  or  initiate  one,  if  none 
is  present.  This  inter-relationship  of  the  stomach  and  intestine 
can  be  explained  upon  the  hypothesis  of  the  close  nervous  connec- 
tion between  the  two  organs,  so  that  a  stimulation  of  gastric  peri- 
stalsis will  likewise  cause  an  increase  of  intestinal  movements. 

A  confirmatory  symptom  of  value  in  the  diagnosis  of  inflam- 
mation of  the  bowel  is  diarrhea,  which  in  acute  enteritis  or  colitis 
is  due  to  irritation  by  indigestible  or  fermenting  substances.  It 
is  of  a  foul  odor  and  contains  frothy  material.  In  tuberculous 
enteritis  the  stool  is  also  foul,  and  contains  blood  and  shreds  of 
tissue.  The  diarrheal  stool  of  an  inflammatory  intestinal  lesion 
(enteritis)  is  generally  acrid,  and  produces  intense  irritation 
around  the  anus  and  buttocks,  while  other  diarrheal  stools,  as  a 
rule,  do  not  excoriate. 

Since  many  of  the  inflammatory  processes  are  accompanied  by 
fermentative  changes  in  the  intestinal  canal,  it  follows  that  a 
considerable  distention  of  the  bowel  from  gas  frequently  is  a  con- 
comitant symptom.  When  it  occurs,  the  pain  of  the  distention  is 
engrafted  on  to  that  of  the 'inflammatory  process. 

In  some  cases  of  inflammation  of  the  bowels  the  inflammatory 
process  is  very  severe  and  extends  to  adjacent  structures.  In  this 
event,  because  of  the  involvement  of  the  peritoneum,  the  sub- 
jective pain  is  associated  with  considerable  local  tenderness,  and 
if  the  cecum  or  lower  end  of  the  ileum  should  be  involved  it  may 
be  confused  with  appendicitis.  This  is  all  the  more  likely  to 
happen  when  the  abdominal  muscles  over  these  areas  are  in  a 
state  of  rigidity,  and  vomiting  and  rise  of  temperature  are  present. 
If  the  inflammation  should  be  in  the  duodenum  the  abdominal 
pain  is  constant,  and  there  is  an  increased  sensitiveness  to  pres- 
sure in  the  right  hypochondriac  region.  Duodenitis  generally  oc- 
curs in  a  patient  suffering  from  an  acute  gastritis,  and  in  the 
stools,  mucus,  with  or  without  blood,  will  be  found.     Duodenal 


LESIONS    OF    THE   INTESTINES    CAUSING   PAIN        487 

digestion,  according  to  O'Connell,  occurs  about  three  o'clock  in 
the  afternoon  and  two  in  the  morning;  therefore,  at  these  times 
the  pain  would  be  most  severe. 

Ulcers  of  the  Intestine.  — The  pain  in  ulcers  of  the  intestine  is 
felt  most  often  in  the  region  of  the  umbilicus,  though  the  exact 
localization  of  the  pain  depends  largely  upon  whether  the  lesion 
is  in  the  small  or  in  the  large  intestine.  In  intestinal  ulceration 
the  pain  is  more  restricted  than  in  inflammation,  and  the  area  or 
point  of  tenderness  does  not  move  about,  as  it  does  both  in  the 
latter  condition  and  in  colics  which  are  the  result  of  eating  indi- 
gestible food.  The  pain  of  ulcer  is  frequently  accompanied  by 
diarrhea,  and  occult  blood  can,  in  some  instances,  be  demonstrated 
in  the  stools.  A  factor  of  importance  in  the  diag-nosis  of  the  loca- 
tion of  the  ulcer  is  in  the  relationship  of  the  attack  of  pain  to  the 
time  of  the  ingestion  of  food.  Should  the  pain  come  on  a  few 
hours  after  eating,  the  duodenum  is  most  likely  to  be  involved ; 
while  if  the  interval  is  longer  the  lesion  is  apt  to  be  lower  in  the 
bowel.  When  an  interval  of  seven  or  more  hours  elapses  before 
the  commencement  of  the  pain,  the  lesion  is  probably  in  the  large 
intestine.  Another  point  of  importance  in  diagnosing  the  loca- 
tion of  an  ulcer  is  that  the  lower  it  is  in  the  bowel  the  less  is  the 
likelihood  of  diarrhea.  If  the  pain  becomes  constant,  and  is  asso- 
ciated with  a  steadily  increasing  distention  of  the  intestine, 
stenosis  of  the  bowel  following  an  ulcer  can  be  diagnosed. 

In  intestinal  ulceration  there  are,  at  first,  intervals  of  freedom 
from  pain ;  but  as  the  bowel  lumen  becomes  narrowed  from  stric- 
ture formation,  tlie  intervals  of  freedom  become  less  and  less,  un- 
til finally  the  pain  is  almost  constant.  This  pain  is  relieved  by 
the  passage  of  the  gas'  present  in  the  occluded  bowel.  Some- 
times rubbing  and  massage,  although  they  may  temporarily  in- 
crease the  pain  by  the  extra  intra-intestinal  pressure  which  they 
produce,  will  finally  cause  a  jjassage  of  the  gas  and  consequent 
relief.  Vomiting  also  appears,  and,  as  the  lumen  continues  to 
narrow,  gradually  becomes  worse,  until  complete  obstruction  oc- 
curs.   It  is  violent,  persistent,  and  stercoraceous. 

In  ulcer  of  the  intestine,  food,  particularly  that  which  is  hard 


488  INTESTINAL   PAIN 

to  digest,  may  act  as  a  local  irritant  and  increase  the  contraction 
of  the  howel,  with  a  consequent  drag  and  pull  upon  the  ulcerated 
area,  and  thus  cause  j^ain.  Unrijje  fruit  or  vegetables,  such  as 
corn  and  cabbage,  are  very  likely  to  act  as  irritating  factors. 

It  is  claimed  by  Schmidt  that  the  application  of  cold  com- 
presses to  the  abdomen  will  relieve  the  pain  of  intestinal  ulcer, 
while  application  of  heat  will  increase  it. 

The  pain  of  ulcers  of  the  intestine  generally  is  not  very 
severe,  except  when  they  occur  in  the  duodenum,  the  sigmoid,  or 
the  rectum.  Large  areas  of  ulceration  in  any  portion  of  the  bowel 
are  very  painful,  esj)ecially  if  the  ulceration  be  deep  enough  to 
involve  the  peritoneuin.  In  these  eases  the  areas  of  local  tender- 
ness over  the  abdomen  are  proportionate  in  size  to  the  area  of  the 
peritoneum  which  is  involved.  In  ulceration  of  the  rectum  tenes- 
mus is  frequent.  The  different  varieties  of  intestinal  ulceration 
are  tuberculous,  typhoidal,  syphilitic,  catarrhal,  uremic,  trophic 
ulcers  and  those  following  burns. 

Tuberculous  Ulcers. — jSTon-progTessive  tuberculous  ulcera- 
tion of  the  intestine  is  often  painless.  Should  the  ulceration  pro- 
gress pain  is  lu-esent.  It  may  be  caused  by  an  associated  enteri- 
tis, intestinal  distention  following  a  stenosis,  a  fermentation,  or 
peritoneal  involvement.  Tuberculous  ulcers  of  the  duodenum,  be- 
cause of  the  frequent  location  of  the  pain  in  the  epigastrium, 
are  often  confused  with  pyloric  spasm  or  gastric  ulcer.  A  diag- 
nostic point  of  value  between  the  two  is  that  in  pyloric  spasm  the 
vomitus  never  contains  bile,  while  in  lesions  of  the  small  or  large 
intestine  usually  it  is  at  least  tinged  with  bile.  Diarrhea  of  a  very 
oifensive  odor  is  frequent  in  tuberculous  ulceration.  Tubercle 
bacilli  may,  in  some  cases,  be  found  in  the  stools.  Reaction  to 
tuberculin,  signs  of  emaciation,  night  sweats,  and  probably  some 
lung  involvement  can  also  be  detected. 

Typhoidal  Ulceration. — Typhoidal  ulceration  is  generally 
painless,  though  in  typhoid  fever  it  is  common  for  the  patient  to 
complain  of  discomfort  in  the  lower  abdomen,  and  in  some  cases 
of  tenderness  in  the  right  iliac  fossa.  If  the  onset  of  the  fever  is 
sudden,  there  may  be  generalized  body  pain  and  headache.     If 


LESIONS    OF    THE    INTESTINES    CAUSING    PAIN        489 

the  development  is  slow  and  gradnal,  and  no  acute  toxic  condition 
is  present,  the  only  pain-phenomena  may  be  a  zone  of  tenderness 
over  the  tenth  or  eleventh  dorsal  visceral  segments. 

Syphilitic  Ulceration. — Syphilitic  ulcers  of  the  bowel,  as 
a  rule,  are  painless.  Should  constant  pain  in  the  abdomen  occur 
in  a  syphilitic,  and  be  accomjmnied  by  diarrhea,  and,  in  some 
cases,  by  vomiting,  a  diagnosis  of  syphilitic  intestinal  ulcer  would 
be  tenable. 

Catarrhal  Ulceration  causes  no  pain,  unless  the  ulceration 
is  very  deep.  The  same  is  true  of  the  ulceration  the  result  of 
uremic  and  troj^hic  changes. 

Ulcers  Following  Burns. — Ulcers  following  burns  are 
common.  They  are  most  frequent  in  those  cases  in  which  the 
burn  is  on  the  abdomen.  When  they  occur  they  are  most  likely  to 
be  in  the  duodenum  (see  Duodenal  Ulcer),  and  give  rise  to  no 
special  symptoms,  other  than  those  which  occur  in  simple  intes- 
tinal ulceration.  The  pain  produced  by  them  is  apt  to  be  over- 
looked by  the  patient,  because  of  the  much  greater  j^ain  which  is 
the  direct  result  of  the  burn. 

Duodenal  Ulcers. — The  pain  of  duodenal  ulcer,  like  that  of 
gastric  ulcer,  is  jDaroxysmal.  It  may  be  of  intense  severity,  or 
may  be  felt  merely  as  a  dull  discomfort  coming  at  certain  inter- 
vals following  the  ingestion  of  food.  In  other  cases,  whether 
severe  or  dull,  it  is  more  lasting,  and  sometimes  a  constant  sense 
of  burning  or  of  sharp  pain  is  experienced.  This  in  many  cases 
is  relieved  by  the  ingestion  of  food,  therefore  it  received  the  name 
"hunger-pain."  The  pain  is  situated  to  the  right  of  the  middle 
line,  and  usually  a  little  above  the  level  of  the  umbilicus.  It 
may  radiate  toward  the  right  or  the  left  side.  Sometimes  it  is 
described  as  having  a  deep-seated  location,  being  rather  unlike 
ihe  characteristic  pain  of  gastric  ulcer  in  this  particular.  The 
time  of  its  appearance  varies.  It  may  follow  immediately  after 
the  taking  of  food,  but  most  often  does  not  api^ear  or,  if  it  does 
appear,  does  not  reach  its  maximum  of  intensity  until  two,  three, 
or  four  hours  after  eating.  The  character  of  the  ingested  food 
has  9,  certain  relationship  to  the  intensity  and  occurrence  of  the 


490  INTESTINAL   PAIN 

pain.  Generally  speaking,  heavy  meals  occasion  a  pain  of  greater 
severity,  although  the  pain  is  later  in  appearance  than  after  light 
meals.  The  drinking  of  copious  draughts  of  water,  or  the  taking 
of  other  liquids,  such  as  milk,  beer,  and  wine,  or  the  ingestion  of 
alkalies,  may  relieve  the  paroxysm  for  a  time. 

Tenderness  and  rigidity  of  the  abdominal  muscles  in  the  right 
upper  segment  of  the  abdomen  may  be  met  with.  Pressure 
usually  increases  the  painful  paroxysms,  although  not  invariably. 
That  the  site  of  the  ulcer  bears  a  relationship  to  the  site  of  the 
pain  cannot  be  doubted,  though  the  idea  that  the  pain,  localized 
tenderness,  and  muscular  rigidity  occur  directly  over  the  site  of  the 
ulcer  is  not  tenable. 

The  pain  in  duodenal  ulcer  may  be  situated  in  the  epigastrium, 
near  the  mid-line,  and  may  extend  to  the  right  so  that  it  lies  be- 
tween the  crest  of  the  ileum  and  the  ribs.  In  this  condition  there 
is  also  often  a  tender  spot  to  the  right  of  the  lower  dorsal  vertebra. 
It  is  claimed  by  many  (Deaver,  among  others)  that  the  pain  in 
duodenal  ulcer  shows  a  tendency  to  periodicity,  so  that  it  may  be 
absent  for  long  intervals  and  then  occur  in  an  attack  of  varying 
intensity.  The  pain  of  duodenal  ulcer  is  increased  by  moving, 
eating,  or  pressure.  In  many  cases  there  is  also  present  in  the 
abdomen  a  feeling  of  gnawing  or  of  boring. 

Many  theories  have  been  advanced  to  account  for  the  pain  in 
duodenal  ulcer.  Three  suppositions  underlie  all  these  theories, 
namely:  (1)  That  the  HCl,  because  of  its  reflex  excess  of  secre- 
tion, directly  irritates  the  ulcer  and  thus  causes  the  pain.  But,  if 
this  is  so,  there  must  be  many  exceptions,  for  a  duodenal  ulcer, 
without  an  excess  of  HCl  in  the  stomach,  is  frequently  found.  In 
fact,  it  seems  that  the  ulcer  is  the  cause  of  this  increase  of  secre- 
tion, and  that  the  only  effect  of  the  excess  is  that  by  irritating  the 
surface  of  the  ulcer,  it  causes  a  reflex  contraction  of  the  pylorus. 
This  leads  us  to  the  second  supposition,  so  actively  championed 
by  Hertz,  (2)  that  the  pain  is  nothing  more  than  a  tension  pain, 
due  to  localized  distention  of  the  stomach  walls,  the  result  of 
excessive  stimulation  from  the  HCl.  It  is  known  that  the  pylorus 
remains  closed  while  the  duodenal  contents  are  acid,  and  that  it 


LESIONS    OF    THE   INTESTINES    CAUSING   PAIN        491 

relaxes  only  when  the  contents  become  alkaline.  In  duodenal 
ulcer  the  duodenal  contents  are,  because  of  the  excessive  secretion 
of  HCl  in  the  stomach,  seldom,  if  ever,  alkaline.  Consequently 
the  stomach  is  always  in  a  state  of  hypertension,  the  result  of 
abnormal  peristalsis.  This  hypertension,  however,  exists  only  on 
the  prepyloric  portion  of  the  stomach,  because  it  is  into  this  por- 
tion that  the  food  is  forced  by  the  peristalsis  and,  being  unable  to 
advance  because  of  the  closed  pylorus,  accumulates  and  causes  the 
increase  of  tension  and  the  so-called  ulcer  pain,  which  has  about 
the  same  location  as  that  described  under  pyloric  spasm.  (3)  A 
third  supposition  is  that  advanced  by  Bier,  wdio  holds  that  a 
stomach  when  empty  has  a  tendency  to  pull  to  the  left,  and  traction 
(in  case  of  duodenal  ulcer)  is  made  upon  the  ulcerated  area,  while, 
on  the  contrary,  a  stomach,  when  full,  is  displaced  to  the  right,  and 
the  traction  is  diminished,  with  a  consequent  diminution  of  the 
pain.  Which  of  these  (if  any,  or  if  all  three)  is  the  active 
factor  in  tha  production  of  pain  in  duodenal  ulcer  is  rather  diffi- 
cult to  decide,  though  it  seems  as  though  all  three  may  have  a 
more  or  less  important  influence. 

Distention  of  the  Bowel.  — Uncomplicated  distention  of  the 
bowel  will  cause  considerable  pain,  especially  when  the  distention 
is  sudden  in  onset,  such  as  is  found  in  acute  obstruction,  strangu- 
lated hernia,  etc. 

In  chronic  intestinal  distention,  pain,  as  a  rule,  is  not  a  promi- 
nent symptom,  and  only  becomes  so  when  there  is  a  sudden  in- 
crease in  the  distention.  The  pain  of  distention  is  relieved  by 
the  expulsion  of  gas,  and  frequently  the  patient  feels  a  change  in 
the  location  of  the  pain  following  a  gurgling  and  the  forward 
movement  of  the  gas.  Distention  of  the  bowel  is  denoted  also  by 
tympany,  localized  over  the  area  of  the  bowel  segment  involved  in 
the  distention.  It  frequently  happens  that  when  the  large  bowel 
is  distended  its  segments  can  be  defined  by  palpation,  and  if  the 
abdominal  wall  is  fairly  thin,  peristalsis,  if  at  all  active,  may  be 
seen.  In  idiopathic  dilatation  of  the  colon  (Hirschsprung's  dis- 
ease) pain  is  usually  absent. 

Adhesions. — Bands  of  adhesions,  which  are  a  common  cause 


492  INTESTINAL   PAIN 

of  distention,  occur  most  frequently  in  connection  with  the  small 
intestine,  and  are  there  a  more  common  cause  of  obstruction  than 
in  the  large  intestine.  They  usually  do  not  produce  pain  unless 
so  placed  as  to  cause,  during  intestinal  digestion  or  on  active 
movements  of  the  body,  a  pull  or  drag  upon  the  parietal 
peritoneum.  They  may  also  cause  pain  by  causing  obstruction  of 
the  bowel. 

Obstruction  of  the  Intestine. — Intestinal  obstruction  is  more 
common  in  the  small  than  in  the  large  intestine.  It  may  be  acute 
or  chronic. 

Acute  Obstruction. — There  are  two  varieties  of  pain  due 
to  acute  bowel  obstruction :  the  primary  and  the  secondary. 

Primary  pain  is  sudden  in  onset,  very  severe,  and  of  a  griping 
character.  It  is  generally  referred  to  the  middle  of  the  abdomen, 
and  is  due  to  the  change  in  the  relationship  of  the  parts  of  the 
bowel,  with  a  consequent  drag  or  pull  upon  the  mesentery  or 
mesocolon.  Following  this  is  the  secondary  pain. ,  It  is  more 
continuous  than  the  primary  pain,  and,  owing  to  the  violent  peri- 
stalsis of  the  cut-off  bowel,  is  interrupted  with  paroxysms  of  great 
intensity.  Gradually,  as  the  result  of  paralysis,  from  exhaustion, 
or  from  toxemia  due  to  poisons  generated  in  the  obstructed  seg- 
ment, the  pain  becomes  less. 

If  the  pain  has  a  tendency  to  spread  from  its  primary  location 
and  is  accompanied  by  concentric  spreading  tenderness,  it  is  an 
indication  that  the  peritoneum  has  become  involved  and  that  a 
spreading  peritonitis  has  ensued.  When  this  occurs  the  pain  is 
sharp,  stinging,  and  more  constant. 

The  cause  of  the  bowel  obstruction  may  be  one  of  the  follow- 
ing: (a)  causes  acting  external  to  the  bowel,  (a)  twists,  volvulus, 
(&)  adhesions,  (c)  intussusception,  (d)  hernial  bands  (see  Her- 
nia) ;  or  (b)  those  acting  within  the  bowel,  as  (a)  contractures, 
(&)  fecal  contents,  (c)  foreign  bodies. 

In  twists  and  intussusception  the  onset  is  sudden  and  the  pain 
is  most  severe.  There  is  also  present  a  well-defined  and  painful 
tumor.  This  tumor,  depending  upon  the  part  of  the  intestinal 
tract  which  is  involved^  is  located  in  different  parts  of  the-  abdp- 


LESIONS    OF    THE    INTESTINES    CAUSING    PAIN        493 

men.  If  the  sigmoid  is  the  part  involved,  the  swelling  first  be- 
gins in  the  left  iliac  fossa,  and  then  gradually  extends  upward, 
with  a  central  tendency,  towards  the  umbilicus.  From  the  very 
beginning  there  are  pain  and  tenderness,  which  become  more 
severe  as  the  lesion  progresses.  The  pain  gradually  extends  until 
the  entire  abdomen  is  involved. 

The  pain  in  intestinal  obstruction  is  due:  (1)  to  inflammation 
of  the  peritoneal  surfaces  and  the  consequent  involvement  of  the 
lymph  nodes;  (2)  the  traction  which  the  inflated  gut  exerts  on 
the  mesentery  and  mesocolon;  and  (3)  irritation  of  the  nerves  in 
the  affected  segment  of  the  bowel  by  (a)  pressure  from  the  ob- 
structing agent,  (&)  pressure  from  violent  peristalsis. 

In  acute  intestinal  obstruction  the  history  of  a  previous  attack 
of  peritonitis  would  indicate  that  the  obstruction  might  be  due  to 
adhesions.  The  pain  in  these  conditions  at  first  is  very  great, 
but  gradually  subsides  if  the  obstruction  persists.  The  tempera- 
ture and  pulse  are  both  variable,  though,  as  a  rule,  no  remarkable 
change  is  noted  in  either.  Vomiting,  though  not  constant,  gen- 
erally is  an  accomj^animent  of  obstruction. 

Sudden,  ad^ite  abdominal  pain,  periodic  in  character,  associ- 
ated with  the  i^assage  of  blood  per  anum,  occurring  in  young 
children,  should  always  lead  to  a  consideration  of  intussusception 
as  a  cause.  Obstruction  accompanied  by  periodic  pain  generally 
means  that  a  volvulus  is  the  cause.  This  gives  rise  to  almost  the 
same  symptoms  as  intussusception,  though  the  tumor  has,  as  a 
rule,  a  different  shape  and  location. 

In  the  early  stages  of  intestinal  obstruction  light  pressure 
upon  the  abdomen  will  often  give  relief.  If  during  the  course 
of  the  disease  the  pain  suddenly  subsides  without  improvement 
in  the  pulse  and  the  general  condition,  the  case  is  serious.  If, 
after  having  ceased,  the  pain  again  commences  and  becomes  rapidly 
generalized,  it  is  a  sign  that  a  generalized  peritonitis  has  developed. 

Cheoxic  Obstkuctioi^. — Chronic  intestinal  obstruction  is 
due  to  adhesions,  contractures,  new  growths,  foreign  bodies  (gall- 
stones, fecal  concretions),  and  inflammatory  processes.  In  these 
the  development  is  slow^  and  extends  over  long  periods,     At  first 


494  INTESTINAL   PAIN 

there  is  oiilj  a  sense  of  discomfort,  which  gradually  becomes 
worse  until  it  is  merged  into  pain.  This  pain  is  intermittent  and 
occurs  in  cramp-like  paroxysms.  These  pains  arise  suddenly, 
and  are  relieved  as  soon  as  the  stagnated  fecal  matter  and  gas 
have  been  forced  beyond  the  point  of  obstruction  by  the  pressure 
from  the  rear.  The  patient  is  also  conscious  of  the  "pain" 
beginning  in  a  certain  spot  and  working  in  a  screw-like  fashion 
up  to  another  sjiot  where  it  ends  (Maylard).  If  the  degree  of 
obstruction  suddenly  becomes  greater  the  pain  immediately  in- 
creases in  intensity,  sometimes  so  markedly  and  suddenly  that  the 
diagnosis  of  an  associated  acute  obstruction  is  made.  What  really 
happens  is  that  only  an  exacerbation  of  an  existing  condition  has 
occurred.  After  a  time  the  pain  again  subsides,  owing,  perhaps, 
to  fatigue  or  to  relief  of  the  local  conditions  (Stengel). 

Early  in  the  course  of  intestinal  obstruction  the  jDain  is  mild, 
paroxysmal  and  infrequent ;  but  as  the  obstruction  becomes  more 
complete,  attacks  of  j^ain  are  more  frequent,  and  are  of  greater 
severity.  Associated  with  the  pain  are  tympanitis,  vomiting  (pos- 
sibly fecal),  visible  peristalsis  (should  the  abdominal  walls  be 
thin),  tumor,  which  is  tympanitic,  obstipation,  and  generally  an 
absence  of  fever.  Previous  attacks  of  localized  peritonitis  or  the 
history  of  an  abdominal  operation  will  suggest  a  band  or  kink 
of  the  intestine  as  a  cause  of  the  obstruction.  The  history  of  a 
tumor  will  suggest  pressure  and  faulty  position  of  an  intestinal 
coil ;  emaciation  in  middle  life  suggests  malignant  disease ;  ascites 
should  lead  one  to  suspect  tuberculosis  (23,  p.  220). 

Maylard  claims  that  pressure  by  hardened  feces  will  also  cause 
pain,  and  he  cites  a  case  where  severe  pain  and  tenderness  were 
present  in  the  right  iliac  region,  and,  on  exploratory  laparotomy, 
only  hardened  feces  could  be  found  in  the  cecum. 

Lesions  of  the  sigmoid  colon  often  cause  pain  of  the  most 
racking  kind.  It  is  felt  at  a  point  usually  about  two  inches  to 
the  right  of  the  umbilicus  and  at  the  upper  part  of  the  iliac  fossa 
at  the  level  of  the  crest  of  the  ilium. 

Overloading  of  the  colon  does  not  seem  to  be  the  cause  of  any 


LESIONS    OF   THE   INTESTINES    CAUSING   PAIN        495 

special  pain.  Constipated  individuals  rarely  suffer  from  pain 
due  to  this  cause  (see  Constipation,  p,  509). 

The  presence  of  indican  in  the  urine  is  a  point  of  considerable 
diagnostic  importance  in  locating  the  site  of  the  obstruction. 
Should  indicanuria  be  present  early  in  the  disease,  it  is  an  indi- 
cation that  the  obstruction  is  high  up,  generally  in  the  small  in- 
testine. At  the  same  time,  in  high  obstructions  there  is  a  reduc- 
tion in  the  quantity  of  the  urine  due  to  the  loss  of  water  from  vom- 
iting, which  is  much  greater  in  lesions  of  the  small  than  in  those 
of  the  large  intestine. 

In  all  cases  of  obstruction  vomiting  is  constant,  and  i&  not 
accompanied  by  nausea.  The  vomitus  at  first  consists  of  the 
contents  of  the  stomach,  then  of  the  bowel,  and  finally  becomes 
fecal.  The  period  at  which  the  fecal  transition  occurs  varies, 
depending  upon  the  segment  of  bowel  involved.  The  lower 
the  involvement  the  longer  is  the  fecal  vomit  in  making  its 
appearance.  Should  the  obstruction  be  as  low  as  the  ileum,  one 
or  two  days  may  elapse  before  it  appears ;  lohen  it  does  appear  it 
is  pathognomonic  of  obstruction. 

The  absence  of  pain  in  bowel  obstruction  may  be  due  to  the 
obstruction  being  the  result  of  paralysis  of  a  portion  of  the  bowel 
distal  to  the  obstruction,  as  in  a  case  reported  by  Musser.  Here, 
the  patient,  five  days  after  an  operation  for  intussusception,  de- 
veloped vomiting,  which  was  of  increasing  frequency  and  finally 
became  fecal,  though  no  pain  was  present.  On  operation  the 
cause  of  the  obstruction  was  found  to  be  a  paralyzed  portion  of 
the  bowel. 

In  resume  it  may  be  recalled  that  obstruction  of  the  bowel 
may  bo  due  to:  (1)  functional  spasm  (colic),  the  result  of  (a) 
irritation,  organic  poisons,  bacteria,  and  cathartics,  (b)  inorganic 
poisons  (lead)  ;  (2)  obstruction  of  the  lumen  by  (a)  lodgment 
of  some  substance,  as  enterolith,  gall-stones,  indigestible  or  fecal 
material,  foreign  bodies,  as  gall-stones,  (b)  change  in  the  relation- 
ship of  the  parts  to  each  other,  as  in  twists  (volvulus),  invagina- 
tion  (intussusception),  dragging  and  pulling  (hernia)  ;  and  (c) 


496  INTESTINAL   PAIN 

the  presence  of  new  gi'owths,  which  may  be  inter-,  intra-,  or  extra- 
mural. 

Volvulus. — Pain  in  volvulus  comes  on  as  a  sharp,  sudden, 
severe  pain  (cramp)  in  the  epigastrium,  or  in  the  region  of  the 
umbilicus.  It  is  continuous,  and  at  first  is  of  a  constant  in- 
tensity; but  as  soon  as  fecal  stasis  occurs,  and  distention  of  the 
bowel  segment  proximal  to  the  obstruction  occurs,  the  constant 
pain  is  interrupted  by  a  series  of  cramp-like  exacerbations. 
These  exacerbations  are  indications  of  the  severe  contractions 
taking  place  in  the  intestine,  in  its  effort  to  establish  a  passage 
through  the  obstruction.  Gradually,  as  the  obstruction  to  the 
circulation  in  the  affected  bowel  becomes  complete,  inflammation 
and  gangrene  supervene,  and  a  generalized  peritonitis,  with  its 
accompanying  pain  and  tenderness,  occurs.  As  the  gangrene 
progresses,  and  the  peritonitis  becomes  more  severe,  sepsis  ensues, 
and  the  patient,  becoming  toxic,  complains  less  and  less  of  pain, 
until,  in  a  state  of  somnolency  and  forgetfulness,  the  shadow  of 
death  hovers  over  him  and  he  passes  into  the  land  of  eternal  rest. 
There  is  no  relief  for  volvulus,  unless  the  knot  is  reduced  either 
by  natural  or  surgical  means. 

Associated  with  the  pain  of  volvulus,  as  described  above,  there 
is  also  present  in  the  abdomen  a  rounded  tumor  mass,  either  tym- 
panitic or  dull  on  percussion.  Obstinate  constipation  and  vomit- 
ing are  also  present,  and  generally,  though  not  invariably,  a  rapid 
pulse.  If  these  symptoms  are  found,  they  are  of  sufficient  mo- 
ment to  demand  a  laparotomy. 

Volvulus  is  most  frequent  at  the  sigmoid.  When  the  condi- 
tion is  acute  and  the  obstruction  is  complete,  a  distention  greater 
than  that  which  occurs  with  any  other  lesion  of  the  bowels  rap- 
idly develops.  Therefore,  when  sudden  pain  is  followed  by  a 
rapid  distention,  without  signs  of  peritonitis,  volvulus  should  be 
considered.  It  is  more  frequent  in  men  than  in  women,  but 
constitutes  only  about  one-fortieth  of  all  cases  of  intestinal  ob- 
struction. 

Intussusception. — This  is  very  frequent  in  infants,  and, 
while  pain  is  undoubtedly  pronounced,  yet  we   are  not  able  to 


LESIONS    OF   THE   INTESTINES   CAUSING   PAIN        497 

make  a  definite  assertion,  because  the  infants,  on  account  of 
their  immature  age,  are  unable  to  express  their  distress.  There- 
fore, should  evidence  of  colic  occur  in  a  baby  (who,  as  frequently 
happens,  has  had  a  previous  diarrhea),  followed,  within  a  short 
time,  by  the  development  and  gradual  increase  in  size  of  an 
elongated  tumor,  with  an  associated  constipation,  a  tentative  diag- 
nosis of  intussusception  may  be  made.  If  the  disorder  should 
happen  in  those  of  more  mature  years,  a  more  detailed  account 
will  be  given  of  the  onset  and  the  nature  of  the  accompanying 
pain.  Bearing  in  mind  the  manner  of  production  of  this  disor- 
der (the  sudden,  acute  invagination  of  one  part  of  the  bowel  into 
another  part,  with  consequent  pull  and  possible  twist  of  the 
mesentery),  the  reason  for  the  sudden  acute  pain  is  apparent. 

It  is  commonly  stated  that  the  pain  in  intussusception  is 
directly  over  the  site  of  the  tumor  mass,  but  the  fallacy  of  this 
is  clearly  proved  in  the  introductory  remarks  to  this  chapter. 
The  pain,  which  at  first  is  of  a  well-defined,  colicky  type,  gener- 
ally is  confined  to  the  umbilical  region  or  lies  immediately  below 
it.  Since  the  lesion  is  located  most  commonly  in  the  cecum  and 
the  lower  part  of  the  ileum,  the  pain  may  finally  become  localized 
in  the  right  iliac  fossa.  This  location  of  the  pain  can  be  ex- 
plained from  the  fact  that,  when  intussusception  occurs,  consid- 
erable pull  is  made  upon  the  mesenteric  attachments  of  the  ileum 
and  is  reflected  as  pain  to  the  anterior  abdominal  wall,  generally 
in  the  region  of  the  umbilicus.  As  the  intussusception  progresses 
an  added  pull  is  made  upon  the  cecum,  and  through  it  traction  is 
exerted  upon  the  parietal  peritoneum,  with  pain  referred  to  the 
right  iliac  fossa,  or  to  the  lumbar  region  on  the  same  side.  Later 
in  the  disease,  owing  to  restriction  of  the  blood  supply  and  to 
pressure,  the  inclosed  segment  of  the  bowel  becomes  necrotic. 
Inflammation  of  the  proximal  segment  then  occurs,  and  is  com- 
municated to  the  adjacent  peritoneum,  with  the  production  of 
pain.  This  pain  is  referred  to  the  area  below  the  umbilicus  and 
across  the  lower  portion  of  the  abdomen.  In  pain-production  the 
pull  and  tension  on  the  mesocolon  also  are  of  considerable  mo- 
ment. 


498  INTESTINAL   PAIN 

In  intussusception  the  lumen  of  the  bowel  is  obstructed,  and 
the  forward  movement  of  feces  hindered.  Backward  stasis 
occurs,  and  distention  of  the  bowel  proximal  to  the  obstruction 
takes  place.  This  distention  then  acts  as  an  additional  cause  ol 
pain-production.  In  invagination  of  the  ileum  into  the  cecum 
the  etiological  relationship  of  the  lesion  to  the  region  where  the 
pain  is  felt  is  illustrated  in  the  accompanying  drawings. 


3  Ro  STAGE 


Fig.  103. — Pain  Areas  in  Intussusception. 
First  stage:  Pull  upon  the  mesentery.  Second  stage:  Pull  on  mesentery  and 
traction  on  parietal  peritoneum  connected  with  the  cecum  and  colon. 
Third  stage:  Inflammation  has  supervened  and  pain  is  also  referred  to 
the  colon  area.  Figure  shows  where  the  pain  is  felt  as  the  bowel  pro- 
gressively becomes  involved  in  the  invagination. 

After  the  intussusceptuni  has  sloughed  off,  provided  the  pa- 
tient survives,  there  is  formed  a  considerable  number  of  adhe- 
sions which,  because  of  their  traction,  are  always  a  source  of  an- 
noyance and  pain-production.  The  bowel  is  also  shortened,  and 
the  mesentery  is  constantly  on  the  stretch ;  and,  though  in  time  it 
may  accommodate  itself  to  its  changed  relations,  at  first  every  little 


LESIONS    OF    THE   INTESTINES    CAUSING   PAIN        499 

(intestinal)  distention  is  noticed  much  more  and  produces  more 
pain  than  it  would  iij.  a  normal  subject. 

If  in  the  sloughing  stage  a  generalized  peritonitis  supervenes, 
the  pain  becomes  much  more  acute  and  is  diffused  over  the  entire 
abdomen.  Tympanitis  also  becomes  more  marked,  and  tenderness 
is  excessive.  In  eliciting  the  tenderness,  the  pressure  exerted 
upon  the  abdominal  wall  must  be  such  that  the  parietal  peri- 
toneum is  irritated ;   pressure  must  be  light  but  not  deep. 

That  there  is  a  somewhat  intimate  relationship  between  peri- 
stalsis and  the  production  of  pain,  and  that  an  absence  of  peri- 
stalsis may  lead  to  an  absence  of  pain,  is  seen  from  a  case  re- 
ported by  Musser,  in  which  an  intussusception  was  present  with 
an  entire  absence  of  pain.  At  the  same  time,  peristalsis  was 
absent.  At  operation  the  intestines  were  found  as  limp  and  as 
motionless  as  they  are  in  a  cadaver.  ^ 

Hernia. — The  obstruction  due  to  hernia  was  considered  under 
hernia  of  the  abdominal  wall  (q.  v.). 

New  Growths  of  the  Intestine. — Xew  growths  of  the  intestine 
frequently  occur  without  the  production  of  pain,  especially  in  the 
early  stages.  When  pain  does  occur,  it  is  due:  (1)  to  interference 
with  the  local  circulation,  causing  congestion,  edema,  inflamma- 
tion, and  adhesions;  (2)  obstruction  to  the  bowels;  (3)  pressure 
on  the  nerve  filaments  in  the  wall  of  the  bowel  or  pressure  upon 
adjacent  nerves;  and  (4)  dragging  and  pulling  on  the  mesentery. 

Interference  wath  the  local  circulation  does  not  produce  any 
pain  until  an  active  inflammation  ensues;  then  pain  becomes  a 
most  marked  symptom.  It  is  localized  to  the  region  over  the 
affected  bowel,  and  is  of  a  peritoneal  type.  If  obstruction  to  the 
bowel  takes  place  the  pain  is  of  the  type  described  under  intesti- 
nal obstruction.  If  it  is  due  to  pressure  on  the  nerve  filaments 
in  the  intestinal  w^all,  the  pain  may  be  reflected  to  the  abdominal 
wall,  and  be  felt  in  the  areas  of  distribution  of  the  ninth,  tenth, 
eleventh,  and  twelfth  dorsal  visceral  segments.  The  higher  the 
point  of  pressure  in  the  bowel  the  higher  the  visceral  segment 
which  is  involved.  If  pressure  should  also  be  made  upon  adjacent 
but  extramural  nerves,  the  pain  is  referred  to  the  area  of  distribu- 


500 


INTESTINAL   PAIN 


tioii  of  these  nerves,  either  in  the  anterior  abdominal  wall  or  in  the 
lower  ]imbs. 

If  a  dragging  and  pulling  on  the  mesentery  occur,  aching  is 
felt  in  the  area  of  distribution  of  the  related  dorsal  visceral  seg- 
ments. 

Pain  Due  to  Colonic  Involvement. — The  colon  is  supplied  by 
nerves  derived,  from  the  superior  and  inferior  mesenteric  plexi, 
which  receive  their  supply  from  the  solar  and  aortic  plexi,  re- 
spectively. These,  in  turn,  receive  their  supply  from  the  ninth, 
tenth,  eleventh,  and  twelfth  dorsal  segments  of  the  cord  (accord- 
ing to  Wilson  (89G),  from  the  seventh  dorsal  to  the  sec- 
ond sacral)  ;  the  segments  most  commonly  involved  are  the  tenth, 
eleventh,  and  twelfth  dorsal.     The  pain  in  colonic  diseases  seems 


Area  in  which  pain  is 
felt  when  the  inflamma- 
tion progresses  along  the 
gastrocolic  omentum 
and  causes  inflamma- 
tion of  the  stomach  and 
adjacent  tissues 


Area  in  which  referred 
pain  is  present 


Fig.  104.  Fig.  105. 

Figs.  104  and  105. — Areas  of  Pain  in  Diseases  of  Colon. 


I.; 


to  be  much  more  pronounced  the  nearer  the  lesion  is  to  the  anus. 
When  the  lesion  is  high  up,  the  pain  is  not  very  severe  unless  in- 
flammation has  extended  to  the  peritoneal  coat  on  either  side  of 
the  mesentery.  If  this  has  occurred,  the  infiltration  may  pro- 
gress to  the  parietal  peritoneum  and  thus  cause  pain,  which,  in 
lesions  of  the  ascending  and  descending  colon,  is  felt  in  the  right 
and  left  lumbar  regions  respectively,  or,  in  those  of  the  trans- 
verse colon,  in  the  center  of  the  abdomen.  Should  only  traction 
of  the  mesocolon  occur,  the  pain  is  felt  in  the  abdomen  in  the 
hypogastric  area. 

This  hypogastric  pain  comes  under  the  class  of  reflected  pains. 
It  is  in  the  zone  of  distribution  of  the  eleventh  and  twelfth  dorsal 


LESIONS    OF   THE   INTESTINES    CAUSING   PAIN        501 

visceral  segments.  The  affections  of  the  colon  giving  rise  to  pain 
are:  (1)  acute  and  chronic  inflammation,  (2)  displacements, 
(3)  obstruction,  (4)  new  growths. 

Inflammation  of  the  Colon. — In  inflammation  of  the  colon 
the  pain  is  referred  to  the  lower  abdomen,  and,  in  involvement  of 
the  sigmoid  flexure,  generally  to  the  left  side.  This  reference  can 
only  be  explained  bv  the  fact  that,  because  of  the  shortness  of  the 
mesocolon  and  its  intimate  association  with  the  peritoneum  of  the 
left  side,  inflammation  of  the  colon  is  quickly  communicated 
to  the  parietal  peritoneum  of  the  same  side.  The  increase  in 
local  tenderness  on  this  side  can  also  be  thus  explained. 

Inflammatory  diseases  of  the  colon  causing  pain  are  of  two 
classes:  (a)  acute  and  (h)  chronic. 

Acute  infective  states  of  the  colon  are  always  painful,  and 
the  pain  is  of  a  griping,  burning,  or  boring  nature.  Pains  the  re- 
sult of  acute  inflammation  have  a  greater  tendency  to  localize 
themselves  to  the  region  of  the  affected  bowel  than  do  the  pains 
produced  by  chronic  disease,  which,  as  a  rule,  are  reflected  or 
referred  to  distant  areas.  In  inflammatory  states  of  the  colon 
the  patient  is  sometimes  conscious  of  a  relief  of  his  pain  follow- 
ing movement  of  the  bowels  or  the  passage  of  flatus.  Mild  inflam- 
matory states  of  the  colon,  as  a  rule,  are  not  painful ;  but  if  the 
irritation  is  prolonged,  and  the  inflammation  increases  and  be- 
comes phlegmonous,  a  septic  and  generalized  bowel  involvement 
or  ulceration,  with  its  somewhat  mild  but  persistent  symptoms, 
may  occur.  In  some  cases  of  painful  colitis  the  ingestion  of  food 
brings  on  an  attack  of  pain.  This  is  due,  probably,  to  activity  of 
the  colon  incited  through  sympathetic  nerve  connections. 

According  to  Tuttle,  there  is  in  ulcerative  colitis  a  "sudden 
onset  of  sharp,  lancinating  pains  in  the  course  of  the  colon, 
attended  with  griping  and  a  tendency  to  frequent  movements  of 
the  bowels.  These  pains  last  for  a  short  time,  then  disappear, 
and  the  patient  may  have  nothing  more  of  the  kind  for  several 
days  or  weeks,  when  they  again  occur.  They  sometimes  last  an 
hour  or  more ;  at  other  times  they  continue  for  two  or  three  days." 
If  the  attack  is  persistent,  pus  and  blood  finally  appear  in  the 


502  INTESTINAL   PAIN 

stools.  The  attacks  are  periodical,  and  the  pain,  which  in  the 
early  attacks  was  not  severe,  increases  in  severity  with  each  at- 
tack. The  amount  of  the  pain  bears  no  relationship  to  the  extent 
of  the  ulceration,  and  is  not  influenced  by  the  ingestion  of  food. 
The  cause  of  the  i:)ain  seems  to  be  the  irritation  of  the  ulcer  by 
the  intestinal  contents,  which  incite  irregular  peristaltic  or  spas- 
modic movement  of  the  bowel.  In  follicular  colitis  there  may  be 
tenderness  over  the  lower  end  of  the  spine,  with  vague  pains 
shooting  down  the  legs. 

In  chronic  colitis  pain  comes  on  at  irregular  intervals.  It  is 
of  a  grij^ing  character,  and  generally  precedes  the  passage  of  a 
stool  consisting  chiefly  of  mucus  or  of  shreds  of  membrane.  After 
the  stool  the  pain  may  persist  for  several  days.  The  onset  of 
the  pain  bears  no  relationship  to  the  ingestion  of  food,  nor  does 
it  seem  to  be  influenced  by  diet.  Tuttle  thinks  that  the  formation 
of  the  membrane  is  the  result  of  a  localized  increase  in  the  secre- 
tion of  mucus,  this  being  the  result  of  a  localized  hyperemia,  which, 
in  turn,  is  due  to  a  slight  intussusception  or  volvulus.  When  the 
spasm  (localized),  which  has  been  the  cause  of  the  intussusception 
or  twist,  relaxes,  the  mucus  or  membrane  which  has  formed  is 
rapidly  discharged.  The  patient,  because  of  the  synchronicity, 
associates  the  jDassage  of  the  membrane  with  the  relief  of  the 
pain. 

Pain  may  be  produced  by  spasm  of  the  colon  without  any  in- 
flammatory lesion  at  the  same  time.  Schiitz  thinks  that  these 
cases  are  most  probably  primary  neuroses.  Any  systemic  crisis, 
such  as  that  occurring  at  the  menstrual  period,  may  bring  them 
on.  The  pains  occur  as  cramps  in  the  sides  and  across  the  abdo- 
men, at  first  only  at  stool,  but  gradually  they  become  more  con- 
stant and  are  interrupted  by  exacerbations  of  agonizing  intensity. 
Constipation  is  pronounced.  Loss  of  appetite,  associated  with 
nausea,  is  present.  This  condition  is  found  usually  in  those  of" 
anemic  and  neuropathic  tendencies.  The  lower  in  the  colon  the 
disease  is  located  the  greater  is  the  tendency  to  pain-production. 
The  reason  for  this  is  that,  filaments  of  the  cerebrospinal  nerves 
are  distributed  to  the  lower  part  of  the  colon,  so  that,  when  this 


LESIONS    OF    THE   INTESTINES    CAUSING   PAIN        503 

part  is  involved,  pressure  will  be  exerted  upon  these  nerves  and 
pain  will  be  produced  in  the  area  of  their  distribution.  It  is  for 
this  reason  that  in  diseases  of  the  sigmoid  flexure  of  the  colon 
pain  has  a  tendency  to  be  localized  in  the  left  lower  abdominal 
quadrant.  In  sigmoiditis  the  patient  flexes  the  left  limb;  the 
abdomen  over  the  sigmoid  is  very  sensitive  to  pressure,  and 
the  lower  segment  of  the  left  rectus  abdominis  is  in  a  state  of 
contraction.  These  symptoms  are  but  indicators  that  the  inflam- 
matory process,  localized  at  first  to  the  walls  of  the  lower  bowel, 
has  spread  by  means  of  the  lymphatics  to  the  adjacent  peri- 
toneum. Such  an  extension  would  be  very  easy,  for  the  sigmoid  is 
without  a  mesentery,  and  is  connected  to  the  body  wall  by  a  loose 
meshed  tissue.  When  peritonitis  occurs  all  movements  of  the  body, 
especially  those  producing  stretching  or  traction  of  the  abdominal 
wall,  are  very  painful.  These  painful  syndromes  are  present  only 
in  acute  cases,  the  chronic  ones  being  entirely  or  almost  entirely 
free  from  pain. 

Often  in  cases  of  mucous  colitis  considerable  pain  is  present 
previous  to  the  discharge  of  casts  of  the  bowel  or  of  large  shreds 
of  mucus.  This  pain  is  relieved  as  soon  as  the  bowel  dis- 
charge commences,  but  abdominal  tenderness  persists  for  some 
time.  Colicky  pains  in  the  lower  part  of  the  abdomen,  on  the  left 
side,  followed  by  tenesmus  and  mucus-stained  stools,  are  pathog- 
nomonic of  sigmoiditis.  Inflammation  of  the  sigmoid  is  very 
rare  without,  at  the  same  time,  an  associated  inflammatory  state 
of  the  rectum.  The  latter  produces  symptoms  similar  in  some  par- 
ticulars to  those  of  inflammation  of  the  colon  and  sigmoid,  but 
differing  in  many  important  details,  because  the  lower  position  and 
the  nearer  relationship  of  the  rectum  to  the  spinal  nerves  cause 
the  pain  to  be  more  that  of  a  referred  spinal  type.  The  rectal 
pain-producing  diseases  will  be  considered  in  a  later  section. 

Displacement  of  the  Colon. — A  rather  poorly  understood 
cause  of  pain  in  colonic  disorders  is  displacement.  That  pain  is 
caused  by  displacement  of  the  colon  cannot  be  doubted,  though, 
at  the  same  time,  the  opinion  is  widely  held  that  displacements, 
even  of  a  major  degree,  may  be  present  without  producing  the 


504  INTESTINAL   PAIN 

slightest  pain.  The  manner  of  the  pain-production  varies  widely, 
depending  upon  the  portion  of  the  gut  involved.  Should  the  dis- 
placement occur  on  either  the  right  or  the  left  side,  the  pull  is 
upon  the  lateral  mesocolon,  and  to  some  extent  upon  the  kidney, 
through  the  nephrocolic  ligament.  If  the  displacement  on  the 
left  side  is  gTcat  enough,  a  pull  upon  the  spleen  also  occurs 
through  the  splenocolic  ligament.  If  the  lesion  is  on  the  right 
side,  traction  is  made  upon  the  li\er  through  the  hepatocolic  liga- 
ment. When  any  of  these  conditions  occur,  aching  and  distress 
are  present  in  the  regions  associated  with  the  organs  secondarily 
involved.  Should  the  transverse  colon  be  affected,  the  pull  is 
exerted  upon  the  stomach  and  the  organs  closely  connected  with 
it,  as  the  pancreas,  liver,  and  gall-bladder,  and  indirectly  upon 
the  diaphragm,  thus  producing  a  symptom-complex  involving  all 
these  organs.  As  they  are  all  supplied  by  the  solar  plexus,  a 
general  aching  and  distress,  sometimes  amounting  to  actual  pain, 
with  an  ill-defined  localization  in  the  lower  abdomen,  result. 

As  a  sequela,  associated  with  displacement,  is  distention.  It 
occurs  from  the  lodgment  of  fecal  matter  at  one  of  the  low  places 
in  the  distended  gut  with  a  consequent  obstruction  and  distention 
of  the  proximal  segment  of  the  bowel  from  gas.  In  some  cases, 
owing  to  the  weight  of  the  fecal  matter,  the  bowel  sags  and  a  kink 
results.  The  onward  progTess  of  the  feces  and  gas  is  obstructed, 
and,  as  a  consequence,  dilatation  of  the  bowel  occurs  on  the  side 
proximal  to  the  obstruction.  The  signs  and  symptoms  of  disten- 
tion (which  are  described  under  that  heading)  then  appear. 

In  a  brief  resume  it  may  be  stated  that  the  localized  pull  upon 
the  peritoneal  attachments  due  to  displacement  produces  signs 
referable  directly  to  the  organs  involved,  while  the  pull  upon 
associated  organs  produces  pain  and  symptoms  referable  to  those 
organs. 

The  consideration  of  the  causes  of  colonic  displacements  is 
beyond  the  scope  of  this  work,  but  a  brief  review  of  the  effects  of 
change  of  position,  etc.,  upon  the  production  and  character  of  the 
pain  may  be  permissible. 

If  the  displacement  is  of  either  the  ascending  or  the  descend- 


LESIONS    OF    THE   INTESTINES    CAUSING   PAIN        505 

mg  colon,  the  position  of  the  patient  lying  upon  the  side  opposite 
to  that  in  which  the  bowel  is  displaced  will  often  cause  consider- 
able and  lasting  pain.  The  pain  is  of  a  dragging,  aching  charac- 
ter, and  may  continue  until  the  patient  turns  upon  the  opposite 
(affected)  side,  and  allows  the  displaced  bowel  to  assume  its 
natural  position,  and  permit  the  gas  and  fecal  matter  to  have 
f\n  unobstructed  passage. 

Displacement  also  causes  a  tumor  formation,  which,  as  a  rule, 
is  tympanitic,  and  varies  in  size,  depending  upon  change  in  the 
position  of  the  patient.  It  can  often  be  reduced  by  pressure, 
the  reduction  being  accompanied  by  audible  gurgling,  and  by  a 
relief  of  the  distress.  An  alteration  of  the  diarrhea  and  constipa- 
tion often  occurs.  When  this  symptom-complex  is  present  it 
should  at  once  attract  our  attention  to  the  colon.  For  other  signs, 
consult  Distention  (cf.  p.  491). 

Should  the  displacement  be  due  to  the  drag  of  a  tumor,  pal- 
pation will  reveal  the  abnormal  formation,  and,  at  the  same  time, 
the  type  of  the  displacement. 

Obstruction. — Obstruction  of  the  sigmoid  by  hardened  feces 
is  a  common  cause  of  pain.  In  this  condition  there  also  may  be 
an  alternate  diarrhea  and  constipation. 

New  growths  cause  pain  as  a  result  either  of  displacement 
or  of  obstruction. 

The  Rectum. — Rectal  pain  is  of  two  classes:  (a)  local  and 
(&)  referred. 

Local  pain  is  due  to  ulcers,  new  growths,  strictures,  etc.  The 
pains  produced  by  these  lesions  are  more  frequently  the  result  of 
involvement  of  the  neighboring  structures  than  of  direct  irrita- 
tion of  the  nerves  ending  in  the  walls  of  the  rectum.  In  all  these 
conditions  there  is,  in  addition  to  the  local  pain,  a  referred  pain, 
which  may  be  felt  in  the  lower  lumbar  or  sacral  regions  of  the 
back,  on  one  or  on  both  sides.  These  regions  are  supplied  by  the 
fourth  sacral  nerve,  which  is  distributed  both  to  the  rectum  and 
to  the  skin  over  the  sacrum.  In  some  cases,  owing  to  associated 
nerve  involvement,  the  pain  may  be  referred  to  the  perineum, 
down  the  back  part  of  the  thigh,  and  even  to  the  penis,  or  to  the 


506  INTESTINAL    PAIN 

labia.  The  upper  part  of  the  rectum  is  without  pain,  and  can  be 
greatly  distended  without  distress.  Because  of  its  non-sensibility 
it  becomes  the  receptacle  of  the  hardened  feces. 

Pain  may  be  referred  to  the  rectum  from  adjacent  organs,  as 
the  uterus,  tubes,  ovaries,  prostate,  posterior  urethra,  or  trigone 
of  the  bladder.  In  these  conditions  the  pain  has  more  of  an 
aching  character,  and  there  is  a  constant  desire  to  go  to  stool. 

ISTervous  disorders  also  cause  pain  referred  to  the  rectum. 
The  following  nervous  disorders,  it  is  said,  cause  rectal  referred 
pain:  epilepsy,  locomotor  ataxia,  neuralgia,  and  hysteria.  It  is, 
however,  a  disputed  question  if  any  nervous  derangement  can, 
without  some  definite  rectal  pathology,  cause  local  rectal  pain. 

The  nerve  supply  of  the  rectum  includes  both  sympathetic  and 
cerebrospinal  nerves.  The  sympathetic  supply  is  derived  chiefly 
from  the  inferior  mesenteric  and  pelvic  plexuses  and  from  the 
nerves  accompanying  the  superior  and  middle  hemorrhoidal  ar- 
teries. 

The  cerebrospinal  nerve  supply  is  derived  from  the  second, 
third,  and  fourth  sacral  nerves,  which  enter  the  sacral  plexus  and 
are  distributed  to  the  rectum  through  the  following  nerves:  (a) 
the  inferior  hemorrhoidal,  which  supplies  both  the  rectum  and  the 
anus;  (6)  the  superficial  perineal,  a  branch  of  the  pudic,  which 
supplies  the  levator  ani  and  the  skin  in  front  of  the  anus.  The 
skin  around  the  anus  is  supplied  by  the  inferior  hemorrhoidal 
branch  of  the  jitudic  (Piersol).  The  pudic  nerve  is  derived  from 
the  same  segment  of  the  cord  as  is  the  sciatic.  Therefore,  irrita- 
tion of  this  nerve  by  ulcer  or  fissure  of  the  lower  rectum  or  anus 
may  be  referred  as  pain  down  the  leg  along  the  course  of  the 
sciatic. 

The  central  origin  of  the  nerve  supply  of  both  the  rectum  and 
anus  is  located  about  the  level  of  the  first  lumbar  vertebra.  This 
is  about  the  same  level  as  that  for  the  bladder  and  genitourinary 
systems.  Thus  we  have  the  explanation  of  the  close  sympathetic 
bond  existing  between  the  two  systems. 

Inflammation  of  the  Rectum. — Inflammation  of  the  rec- 
tum, called  proctitis,  as  a  rule,  is  of  little  moment,  unless  it  passes 


LESIONS    OF    THE   INTESTINES    CAUSING   PAIN        507 

tlie  catarrhal  stage  and  becomes  of  a  dysenteric  type.  Proctitis  of 
the  catarrhal  type  may  give  rise  to  no  symptoms  except  a  sense  of 
distress  in  the  rectum,  and,  in  some  instances,  an  aching  referred 
to  the  back  over  the  sacrimi.  Pathognomonic  of  catarrhal  proctitis 
are  griping  pains  in  the  lower  abdomen,  with  constipation,  and, 
in  some  cases,  nausea  and  vomiting.  In  addition  to  these  symp- 
toms, there  is  at  times  the  occasional  passage  of  a  small  quantity 
of  blood-stained  mucus.  Should  constipation  be  pronounced,  the 
stools  hard  and  dry,  and  tenesmus  and  sacral  pain  marked,  trophic 
proctitis  is  most  likely.  Rectal  tenesmus  is  present  in  all  vari- 
eties of  proctitis. 

In  proctitis  hemorrhoids  are  almost  constantly  present,  and 
should  not  be  mistaken  for  the  disease ;  nor  should  pruritis,  which 
often  is  severe,  lead  one  astray  in  making  the  diagnosis. 

Dysenteric  proctitis  is  the  most  severe  form  of  rectal  inflam- 
mation. It  causes  the  most  pronounced  aching  in  the  pelvis  and 
about  the  anus,  and  also  produces  ''burning  and  heat  in  the  lower 
.  part  of  the  rectum,  severe  tenesmus,  constant  diarrhea,  and  rapid 
exhaustion." 

Xew  Geowths. — The  new  gTOwths  of  the  rectum  causing 
pain  are  carcinoma  and  giimmata.  Carcinoma  of  the  rectum,  if 
it  is  above  the  mucocutaneous  folds,  is  generally  painless.  One 
of  the  unfortunate  things  about  this  dread  disease  is  that  its  onset 
is  so  insidious  and  symptomless  that  its  cryptic  advance  is  not 
suspected  until  it  has  progressed  so  far  that  treatment  is  of  no 
avail.  Yet,  because  of  the  morning  diarrhea  and  the  discharge  of 
pus  and  blood,  attention  should  be  focused  early  upon  the  rectum 
as  the  seat  of  the  trouble. 

Gummata  of  the  rectum  are  painless.  At  the  anus  they  are 
inversely  as  frequent  as  are  the  primary  lesions  in  the  same  loca- 
tion. The  probable  reason  for  the  lack  of  pain  in  gummata  of  the 
rectum  lies  in  the  fact  that  they  are  seldom  accompanied  by  inflam- 
matory reactions,  and  pain,  if  it  is  "present,  is  chiefly  caused  by 
distention,  and,  because  of  the  laxity  of  the  tissues  at  this  place, 
is  very  hard  to  produce.     Another  reason  for  the  absence  of  pain 


508  INTESTINAL   PAIN 

is  that  gummata  rarely  suppurate,  and,  therefore,  the  nerves  are 
but  seldom  involved  in  an  inflammatory  process. 

Ulceration. — The  most  common  cause  of  rectal  pain  is  ul- 
ceration, and  I  cannot  do  better  than  quote  from  Tuttle,  who 
so  thoroughly  covers  the  subject.  He  says  that  in  this  condition 
"pain  is  a  very  sharp,  unreliable,  and  indefinite  symptom.  Cer- 
tain individuals  suffer  greatly  from  it,  while  others  have  no  pain 
at  all.  If  the  ulceration  is  high  up  in  the  rectum,  a  sense  of 
weight  and  aching  in  the  sacral  region  is  the  chief  discomfort  of 
which  most  patients  complain,  while,  if  it  is  situated  lower  down. 
within  the  grasp  of  the  sphincter  and  involves  the  mucocutaneous 
fold,  which  is  rich  in  sensory  pain-receptors,  pain  of  a  sharp, 
lancinating,  burning  character  will  be  the  chief  complaint.  This 
pain  is  the  result  of  contraction  of  the  internal  sphincter,  which 
makes  pressure  upon  the  exposed  sensory  receptors.  The  amount 
of  the  pain  varies  considerably  with  the  character  of  the  ulcera- 
tion. Tuberculous  ulcers  are  almost  entirely  free  from  pain. 
Syphilitic  ulcers  vary  considerably  in  the  amount  of  pain  which. 
they  produce.  Sometimes  they  are  very  sensitive;  at  other  times 
the  patient  is  almost  entirely  free  from  pain.  This  freedom  de- 
pends, to  a  considerable  degree,  upon  the  location  of  the  ulcer. 
As  a  rule,  ulceration  of  the  rectum  is  not  an  acutely  painful  affec- 
tion." 

Varicose  ulcers  of  the  rectum,  because  of  their  location  above 
the  mucocutaneous  fold,  are  a  rather  negligible  quantity  as  a 
cause  of  acute  pain.  However,  there  is  present  a  dull  aching  in 
the  back,  and  sometimes  shooting  pains  run  down  the  leg  or 
around  the  pelvis.  Should  the  sphincter  be  involved,  the  pain, 
because  of  the  excessive  contraction  of  this  muscle,  becomes  very 
acute.  If  the  varicosities  are  large  enough  to  be  termed  hemor- 
rhoids, the  pain  is  much  more  severe.  It  is  especially  marked 
should  the  hemorrhoid  be  of  such  a  size  that  it  can  prolapse 
through  the  anus  and  be  grasped  by  the  sphincter.  Hemorrhoids 
may  cause  pain  referred  over  the  sacrum,  in  the  back,  and  down 
the  limbs. 


LESIONS    OF    THE    INTESTINES    CAUSING   PAIN        509 

Ulceration  accompanying  Bright's  disease  usually  is  without 
pain. 

Ischiorectal  Abscess. — In  ischiorectal  abscess  the  infec- 
tion is  generally  ushered  in  by  a  well-defined  chill,  and  a  feeling 
of  discomfort  which  is  soon  followed  by  a  throbbing  pain.  Ex- 
amination reveals  an  induration  around  the  anus ;  redness  may 
or  may  not  be  present,  depending  upon  the  extent  and  severity 
of  the  infection.  The  patient  generally  has  difficulty  in  urina- 
tion, and  defecation  may  be  and  usually  is  extremely  painful. 
In  some  cases  a  hematoma  may  simulate  an  ischiorectal  abscess, 
but  on  opening  the  swelling  the  only  thing  found  is  a  collection 
of  blood.    As  soon  as  this  is  evacuated  the  pain  disappears. 

Pain  Due  to  CoxsTiPATioisr. — ISTeuralgia  is  often  associated 
with  constipation.  This  is  due  in  large  part  to  direct  pressure 
by  the  fecal  mass  upon  a  nerve  or  a  nerve  plexus.  Continued 
pressure  causes  traumatism,  and  leads  to  a  pressure  neuritis. 
Lowered  vitality  of  the  nerve-stem,  due  to  pressure,  also  permits 
infection.  Thus,  there  may  develop  an  infectious  neuritis,  as 
well  as  a  pressure  neuritis. 

Constipation. — Colicky  pains  are  produced  by  constipation, 
and  are  the  result  of  the  distention  of  the  bowel  by  gas  or  fecal 
matter,  or  they  may  be  the  result  of  enterospasm,  due  to  irritation 
from  the  stagnated  feces,  or  their  contained  toxins.  These  pains 
are,  as  a  rule,  localized  in  the  central  part  of  the  abdomen.  The 
abdominal  muscles  are  sometimes  associated  in  the  symptom-com- 
plex and  are  strongly  contracted.  Frequently  the  contraction  of 
the  muscle  is  confined  to  the  portion  which  lies  over  the  area  of  the 
involved  bowel. 

The  Anus. — The  lowest  part  of  the  rectum,  the  anus,  is  the 
part  most  subject  to  painful  reactions.  These  are  the  result  of  two 
factors :  ( 1 )  the  gi'eat  sensitiveness  of  the  sensory  receptors  in 
tliis  location,  and  (2)  the  presence  of  two  powerful,  constant  act- 
ing sphincters,  whose  contraction  produces  severe  pressure  upon 
the  exposed  and  irritated  nerve  filaments.  Because  of  these  con- 
ditions, the  slightest  ulcer  in  this  area  is  provocative  of  the  most 
extreme  distress.     The  nerve  stimuli  from  the  anus  areas  are  con- 


510 


INTESTINAL    PAIN 


veyed  in  the  fifth  sacral  nerve,  which  also  supplies  the  integu- 
ment over  the  sides  and  the  tip  of  the  coccyx.  This  accounts  for 
the  referred  pain  felt  over  this  area  in  anal  disorders. 


H«nonhoKla\Alnte(3.  Around 
^*  ^    Sphincter 


Fig.  106. 


-Irritation  at  External  Sphincter  Referred  to  Skin  over 
Coccyx. 


Anal  Fissure. — The  most  painful  of  the  anal  affections  is 
a  narrow  and  deep  ulceration  of  the  mucocutaneous  junction,  the 
so-called  anal  fissure.^  The  pain  produced  by  this  lesion  is  of 
two  types,  depending  upon  the  stage  of  development.  In  the  early 
stages  the  nerve  endings  are  exposed  on  the  ulcerated  surface,  and 
the  pain  is  of  a  cutting,  burning  type,  most  marked  after  defeca- 
tion. Later,  as  the  sensitory  fibers  which  have  been  exposed  are 
destroyed,  the  pain  is  more  dull  and  constant.  During  the  course 
of  the  ulcer,  owing  to  infection,  and  possibly  traumatism  of  the 
adjacent  nerves,  a  peri-  and,  in  some  cases,  an  interstitial  neu- 
ritis may  develop.  There  is  then  present  a  dull,  throbbing  ache, 
which  radiates  to  the  back  and  down  the  legs.  This  pain  may 
persist  even  after  the  ulcer  has  cicatrized,  because,  even  though 
the  ulcer  may  heal  perfectly,  the  neuritis  will  still  remain. 

^  In  anal  fissure  pressure  upon  the  margin  of  the  anus,  just  below  the 
ulcer,  is  always  painful.  A  large  part  of  the  distress  may  be  prevented, 
should  the  patient  lie  down  immediately  after  defecation.  When  the  pain  has 
persisted  for  some  time  it  may  be  permanently  relieved  by  forcible  divulsion 
of  the  sphincter.  The  relief  of  pain  by  this  means  seems  to  be  due,  as  de- 
scribed by  TuttJe,  to  the  release  of  the  nerves  from  inflammatory  adhesions 
with  which  they  were  surrounded,  and  to  the  removing  of  the  pressure  which 
had  previously  been  exercised  by  the  tightly  constricting  sphincter. 


LESIONS    OF    THE   INTESTINES    CAUSING   PAIN        511 

The  descrij^tion  of  the  pain  of  anal  fissure  given  by  Tuttle 
is  worth  quoting.  He  says,  ^'The  pain  is  very  variable  in  time, 
nature,  and  duration.  It  may  come  on  at  stool,  immediately 
thereafter,  or  half  an  hour  or  an  hour  after.  It  may  be  acute, 
cutting,  tearing,  as  if  a  wound  were  being  pulled  asunder,  or  it 
may  be  a  burning,  hot,  irritating  feeling,  accompanied  with  spasm 
and  bearing-down  sensation.  Finally,  it  may  have  none  of  these 
characteristics,  but  assume  a  dull,  heavy  ache,  with  throbbing  and 
distress  similar  to  that  of  an  aching  tooth.  The  time  during 
which  the  pain  lasts  is  also  as  variable  as  its  nature.  Sometimes 
it  lasts  for  only  a  few  minutes,  and  the  patient  is  then  able  to 
go  about  his  business  without  any  further  disturbance  till  the 
next  stool.  At  other  times  the  pain  and  smarting  are  so  severe 
that  he  is  unable  to  move  from  his  position  at  the  toilet,  or  he 
must  seek  his  bed,  and  lie  there  from  one-half  to  three-quarters  of 
an  hour  until  the  acute  agony  has  passed  away.  After  this  he  is 
comparatively  comfortable  for  the  rest  of  the  day.  In  others,  the 
pain  does  not  come  on  for  some  little  time  after  the  fecal  move- 
ment, when  smarting  and  burning  are  felt  in  the  anal  region. 
This  sensation  gradually  changes  to  a  throbbing,  aching  distress 
about  the  anus  and  the  sacrum,  which  may  last  for  several  hours, 
or  even,  in  some  cases,  all  day  long.  Certain  patients  are  never 
entirely  free  from  discomfort.  There  is  a  pretty  clear  relation- 
ship between  these  pains  and  the  character  of  the  fissure. 

"The  acute  j^ains,  lasting  only  for  a  few  moments,  are  ordi- 
narily due  to  superficial  fissures  which  involve  the  uppermost 
layers  of  the  mucocutaneous  tissues,  healing  partially  from  day 
to  day,  and  recurring  with  each  hard  stool.  They  can  be  pro- 
duced by  forcibly  stretching  the  anal  folds  apart.  Such  fissures 
are  frequently  associated  with  atrophic  catarrh  and  late  syphilis. 
The  pains,  which  come  on  just  after  stool  and  last  for  one-half 
an  hour  or  more,  are  ordinarily  due  to  an  ulceration  between 
the  radial  folds  of  the  rectum,  especially  in  the  posterior  com- 
missure. There  is  a  slight  red  granulated  base,  thickeniug  of  the 
edges,  with  a  sentinel  pile,  or  two  little  teats  at  its  lower  end. 
The  dull   aching  or  throbbing  pain,  which  comes   on  some  time 


512  INTESTINAL   PAIN 

after  stool,  is  geiieraliy  due  to  a  fissure  or  ulceration  in  the  upper 
part  of  the  anus,  and  involves  the  internal  and  the  upper  fibers 
of  the  external  sphincter.  It  is  ordinarily  of  long  standing, 
deeper,  and  more  indurated  than  the  previous  variety,  hut  its 
edges  are  not  so  elevated  and  thickened,  and  it  does  not  involve 
the  skin  at  all,  and  can  only  be  seen  by  the  use  of  the  speculum,  or 
by  forcibly  stretching  the  anus  apart.  The  late  pains,  occurring 
some  time  after  a  fecal  movement,  indicate  that  the  ulceration 
is  high  up,  while  those  occurring  immediately  thereafter  would 
indicate  a  lower  situation.  In  general,  however,  it  may  be  said 
that  the  acuteness  and  severity  of  the  pain  are  in  direct  propor- 
tion to  the  nearness  of  the  ulcer  to  the  anal  margin.  The  more 
the  mucocutaneous  tissue  is  involved  the  greater  is  the  pain. 
The  reason  of  this  is  probably  that  the  sensitive  nerve  fibers 
approach  the  mucous  membrane  from  below,  and  are  distributed 
in  a  gradually  decreasing  ratio  as  we  ascend  into  the  anal  canal, 
disappearing  almost  entirely  after  the  mucous  membrane  has  been 
reached."  ^ 

The  reflex  pains  associated  with  anal  fissure  are: 

(1)  Dysuria. — This  generally  occurs  at  the  time  of  or  shortly 
following  defecation.  This  association  is  easily  understood  when 
it  is  considered  that  the  anus  and  the  lower  urinary  system  re- 
ceive their  nerve  supply  from  the  same  segment  of  the  cord. 

(2)  Uterine  and  bearing-down  pains  (in  women). 

(3)  Backache  and  neuralgic  pains  shooting  down  the  leg. 

(4)  Facial  and  occipital  neuralgic  pains. 

The  neuralgia  may  be  but  an  indication  of  the  reaction  of  the 
nerves  to  the  toxins  which  are  circulating  throughout  the  system, 
because,  in  anal  fissure,  the  bowels,  on  account  of  the  pain,  are 
inactive,  and  the  fecal  matter  accumulates,  giving  rise  to  a  toxemia. 

Perianal  Abscesses. — Some  perianal  disorders  are  ex- 
tremely painful.  Of  these  abscesses  are  the  most  painful.  Should 
an  abscess  be  present  in  the  subcutaneous  tissue  around  the  anus, 
and  no  pain  be  felt,  it  is  a  fairly  good  indication  that  the  condi- 
tion is  due  to  tuberculosis.     In  such  affections  there  is  very  little 

*" Diseases  of  the  Anus  and  Pelvic  Colon,"  p.  300. 


LESIONS    OF    THE    INTESTINES    CAUSING   PAIN        513 

inflammatory  reaction,  and  swelling  and  redness  are  absent.  The 
discharge,  thin  and  watery,  passes  out  of  a  small  opening  which 
leads  from  a  boggy  central  mass.  All  cases  of  fistula,  abscess,  and 
ulcer  around  the  rectum,  which  have  developed  insidiously  with- 
out pain,  are  generally  tuberculous.  Should  the  abscess  not  be 
tuberculous,  but  the  result  of  an  infection  from  a  pyogenic  organ- 
ism, there  is  at  first  a  preliminary  feeling  of  discomfort,  quickly 
followed  by  sharp  and  severe  pain.  Examination  will,  in  this 
case,  disclose  a  small,  round,  inflammatory  area,  which  is  hot 
and  red,  and  exquisitely  tender  to  the  touch.  The  patient  also 
has  fever  and  an  increase  in  the  pulse  rate. 


CHAPTER  XXV 

THE    APPENDIX 

The  appendix  is  located  in  the  right  iliac  region  at  a  point 
about  two  inches  from  the  umbilicus  on  a  line  running  from 
the  umbilicus  to  the  anterior  superior  spine  of  the  ilium.  It  gen- 
erally lies  deep  in  the  abdominal  cavity,  and  has  no  direct  connec- 
tion with  the  abdominal  wall.  As  a  rule,  it  and  the  adjacent 
loops  of  the  bowels  are  covered  by  the  omentum,  which  hangs 
over  and  protects  them  from  injury,  either  traumatic  or  infective. 

It  is,  in  the  majority  of  cases,  free,  although  its  excursions 
and  movements  are  somewhat  restricted  by  a  short  mesentery 
which  joins  the  right  leaf  of  the  mesentery  proper  and  is  called 
the  mesoappendix.  Through  this  mesoappendix  the  appendix 
derives  its  blood  and  nerve  supply.  The  blood  supply  is  derived 
most  frequently  from  the  posterior  branch  of  the  iliocecal  artery, 
formed  from  the  junction  of  a  branch  from  the  iliocolic  with  one 
from  the  colica  dextra.  The  nerve  impulses  are  carried  through 
the  superior  splanchnic  of  the  sympathetic. 

The  researches  of  Neumann  (127b)  have  definitely  shown  that 
the  splanchnics  convey  painful  sensations  to  adequate  (tension) 
stimuli. 

The  pain  ^  in  appendicitis  is,  in  the  early  stages  of  the  attack, 
found  to  be  general,  or,  as  it  is  termed,  diffuse,  being  distributed 
over  the  entire  abdomen,  though  frequently  it  is  first  perceived 
in  the  epigastric  or  umbilical  region.  Then  it  becomes  localized 
to  the  region  of  the  appendix  and,  as  the  peritoneum  becomes  in- 
volved, it  again  spreads.     In  gangrenous  appendicitis  there  often 

'  The  nervous  system  of  woman  reacts  to  pain  more  readily  than  does 
that  of  man   (265,  p.  408). 

5U 


THE   APPENDIX 


515 


is  lack  of  i^aiii,  assumed  to  be  due  either  to  benumbing  of  the  pain 
receptors  by  the  toxemia,  or  possibly  because  there  are  no  peristal- 
tic waves  set  up  in  the  appendix.  The  diffuse  pain  is  probably  due 
to  an  explosion  of  nervous  impulses,  which  are  produced  in  the 
appendix  by  the  sudden  distention  and  consequent  traction  thus 


Right  side  shows  cuta- 
neous distribution 


X  Thoracic  nerve 
xi  Thoracic  nerve 
xii  Thoracic  nerve 


Left  side  shows  muscu- 
lar distribution 


Fig.  107. — Cutaneous  and  Muscular  Distribution  of  11th  and  12th 

Thoracic  Nerves. 

It  is  seen  that  the  eleventh  thoracic  supphes  principally  the  lower  segment 
of  the  rectus  abdominis  muscle.  Thus  since  this  segment  is  the  one 
usually  connected  with  the  appendix  it  is  easy  to  understand  the  reason 
for  the  local  and  segmental  contraction  of  the  rectus  muscle  in  appen- 
diceal inflammatory  states. 


induced  upon  the  mesoappendix.^  It  has  been  stated  by  Lennan- 
der  ^  that  all  pain  arising  from  intraabdominal  changes  is  due  to 
peritoneal  traction  produced  by  these  changes.  The  secondary  pain, 
which  becomes  localized  to  the  region  of  the  appendix,  may  be  due 

'Moullin  (226,  p.  515)  claims  that  the  initial  pain  of  appendicitis  is  due 
to  the  "peristaltic  action  of  the  cecum  or  of  the  appendix  dragging  upon  the 
attachment  of  the  cecum  to  the  abdominal  wall."  When  the  inflammation 
spreads  to  the  muscular  coat  the  latter  can  no  longer  contract,  and  as  a  conse- 
quence the  pain  ceases.  Moullin  also  claims  that  such  a  relationship  is  shown 
by  the  fact  that  the  cessation  of  the  umbilical  pain  is  coincident  with  the 
formation  of  a  local  swelling  "due  to  distention  of  the  bowel  and  the  thicken- 
ing of  its  walls  by  inflammatory  exudate." 

^Lennander's  explanations,  however,  as  has  been  repeatedly  pointed  out, 
are  not  valid,  because  of  the  oversight  of  what  constitutes  an  adequate  stimu- 
lus for  the  internal  viscera. 


516  THE   APPENDIX 

to  involvement  of  tbe  terminal  sensory  filaments  of  the  spinal 
nerves  distributed  to  the  appendix.^  These  refer  the  sensation  to 
their  terminal  somatic  filaments  and  the  abdominal  wall  and,  since 
the  eleventh  spinal  segment  (Deaver)  is  connected  with  the  appen- 
dix, the  pain  will  be  referred  to  the  filaments  of  distribution  of  this 
segment.  The  principal  points  of  emergence  of  these  nerves  are 
near  McBurney's  point,  thus  accounting  for  the  pain  in  this  neigh- 
borhood. 

It  is  also  possible  for  an  appendix  to  be  inflamed  and  give 
rise  to  no  symptoms.  For  example,  in  many  cases  I  have  exam- 
ined appendices  where  strictures  were  present,  indicating  an  old 
inflammatory  reaction,  and  yet  the  patient  was  unable  to  recall 
any  attacks  of  pain  resembling  an  appendicitis. 

Varieties  of  Appendiceal  Pain. — Pain  in  appendicitis  may 
be  divided  into  the  following  classes ; 

I.  Local  pain  due  to: 

(1)  (a)   Obstruction. 

(&)   Inflammatory  swelling. 

(2)  Inflammation: 

(a)   Mural. 

(h)   Extramural. 

(3)  Adhesions: 

(a)   To  other  abdominal  viscera. 
(6)   To  the  peritoneum. 

II.  Distant  pain,  which  may  be: 

(1)  Referred  pain: 

(a)   To  the  abdominal  wall  of  the  same  side. 
(h)    To  the  tunica  vaginalis  testis  and  also  to  the 
sacroiliac  region. 

(2)  Transferred  pain: 

(a)   To  the  abdominal  wall  of  the  same  side,  at  a 

higher  or  lower  level. 
(h)   Crossed   to    the    abdominal   wall   of   the   other 

side,  at  the  same  or  at  a  higher  or  lower  level. 

^  It  is  questionable  whether  the  terminal  filaments  of  any  spinal  nerve 
ever  really  reach  the  appendix. 


VARIETIES    OF    APPENDICEAL    PAIN  517 

(3)   Keflex: 

(a)  Headaches. 
(5)   Reflected  pain. 

Local  Pains. — (1)  Obstruction. — The  local  pains  are  due 
to:  appendiceal  colic,  the  result  of  obstruction  of  the  lumen  of 
the  appendix  by  (a)  some  indigestible  food,  (&)  a  foreign  body, 
(c)  a  kink  in  the  appendix,  or  (d)  constriction  by  adhesions. 

(a)  In  some  cases  indigestible  food,  as  the  chaff  of  the  wheat 
grain,  or  of  any  other  cereal,  or  the  seeds  of  various  fruits  and 
berries  lodge  in  the  appendix,  and,  because  of  diminished  muscu- 
lar power,  it  is  unable  to  extrude  them ;  consequently,  they  re- 
main in  its  lumen  and  are  a  source  of  irritation.  This  irritation 
is  the  signal  for  the  gathering  of  germs  which  produce  a  mild 
grade  of  inflammation;  and,  as  a  consequence  of  it,  fermentation 
and  a  slight  dilatation  of  the  lumen  occur ;  this  in  turn  stimulates 
contraction,  and  this  causes  the  pain,  (h)  Foreign  bodies  may 
lodge  in  the  appendix,  as  fecal  concretions,  or  seeds,  (c)  Kinks 
may  occur  in  the  appendix.  In  these  conditions  the  bend  in  the 
appendix  hinders  the  emptying  of  its  lumen;  consequently,  there 
is  an  accumulation  of  secretion  and  fecal  material  on  the  side 
distal  to  the  obstruction.  This  causes  distention,  with  a  conse- 
quent tendency  of  the  appendix  to  straighten  out,  and  there  re- 
sults a  great  pull  and  drag  uj^on  the  segment  of  the  mesoappendix 
to  which  the  distended  segment  is  attached.  This  either  initiates 
a  pain  or  adds  to  the  pain  which  is  already  present.  If  the  obstruc- 
tion is  near  the  end  of  the  appendix,  and  the  appendix  is  unable 
to  contract,  there  is  little,  if  any,  pain  from  the  obstruction,  (d) 
The  active  causative  factors  of  pain  due  to  constriction  by  ad- 
hesions are  the  same  as  when  kinks  are  present. 

Obstruction  may  be  due  to  an  inflammatory  swelling,  which 
causes  a  blocking  of  the  lumen  of  the  appendix,  distal  to  which 
the  distention  occurs,  with  consequent  pain  production. 

(2)  Inftammation. — The  pain  of  appendiceal  colic  is,  in  many 
instances,  due  to  an  associated  inflammation  of  the  ileum,  because 
of  which  the  peristaltic  waves  become  painful.     This  adjacent  iu- 


518  THE   APPENDIX 

flammation  is  more  definitely  indicated  bj  the  close  association  of 
these  attacks  and  the  subsequent  diarrheas. 

Inflammation  of  the  appendix  may  be  divided  into  three 
stages : 

(a)  Inflammation  which  is  confined  to  the  mucous  and  the 
submucous  coat.  Often,  in  this  condition,  no  actual  pain  is  pres- 
ent; rather  there  is  a  sense  of  discomfort,  which,  as  a  rule,  is 
referred  to  the  region  of  the  umbilicus.  This  is  the  class  of 
cases  in  which  the  complaints  are  mainly  digestive,  such  as  pres- 
ence of  gas  in  the  stomach  and  intestines,  distress  after  eating,  and 
a  tendency  at  times  to  nausea  and  vomiting.  These  symptoms 
are  but  the  reflex  indications  of  a  sympathetic  involvement. 
Should  the  onset  of  the  inflammation  be  sudden,  the  shock  to 
the  sj'mjDathetic  system  is  greater,  tbe  above  symjDtoms  are  in- 
creased, and  a  well-marked,  referred  pain  is  present. 

(&)  Inflammation  of  the  muscular  coat  follows  closely  upon 
that  of  the  mucous.  To  the  above  symptoms,  well-defined  local 
pains  are  now  added.  These,  following  closely  upon  signs  of 
mucosal  involvement,  are  a  sure  indication  that  inflammation  is 
spreading. 

(c)  Involvement  of  the  peritoneal  coat  nearly  always  occurs 
if  the  inflammation  is  severe.  This  happens,  as  a  rule,  only  in 
acute  processes;  that  the  peritoneal  coat  may  be  involved  in  a 
chronic  inflammation  is  possible ;  but  by  far  the  vast  majority  of 
peritoneal  inflammations  arise  from  an  acute  inflammation.  If 
tlie  attack  is  acute  and  the  inflammation  has  advanced  to  the 
peritoneum,  there  is  then  present  a  greater  intensity  of  the  cuta- 
neous hyperalgesia  and  referred  pain.  Following  the  onset  of  the 
local  pain,  also,  in  some  cases,  in  which  the  appendix  is  so  situ- 
ated that  it  lies  in  close  contact  with  the  parietal  peritoneum, 
this  layer  also  becomes  involved  in  the  inflammatory  process.  The 
local  peritonitis  is  then  manifested  by  exquisite  local  tenderness. 
With  peritoneal  involvement  the  sympathetic  reflex  symptoms  are 
increased;  nausea  and  vomiting  occur,  local  peristalsis  ceases, 
constipation  ensues,  distention  of  the  bowel  comes  on,  and  symp- 
toms of  toxemia  appear.     These  are  accompanied  by  an  elevation 


VARIETIES    OF    APPENDICEAL    PAIN  519 

of  temperature  and  a  rise  of  the  pulse  and  respiratory  rate.  An- 
other sign  of  importance  (reflex  in  nature)  is  the  cessation  of  dia- 
phragmatic breathing  as  soon  as  the  peritoneum  becomes  involved. 
It  is  of  importance,  in  deciding  the  extent  of  involvement,  to 
note  the  presence  or  absence  of  irritative  peristalsis  in  the  cecum. 
The  manner  of  obtaining  this  is  suddenly  and  lightly  to  palpate 
over  the  appendiceal  region,  having,  at  the  same  time,  the  bowl  of 
the  stethoscope  over  the  cecal  region ;  should  the  peritoneum  be  in- 
volved, no  peristalsis  will  take  place;  should  the  peritoneum  not 
be  involved,  peristalsis  will  immediately  follow.  This  sign  has 
been  elicited  in  many  cases. 

(3)  Adhesions. — Should  adhesions  from  the  appendix  drag 
upon  the  parietal  peritoneum,  the  pain  is  sharply  localized  to  the 
area  of  adhesion,  is  of  a  dragging  nature,  and  is  worse  when  cer- 
tain positions  are  assumed  by  the  patient.  A  right  lateral  recum- 
bent posture  often  seems  to  be  conducive  to  the  induction  of  this 
pain.  Active  movements,  also,  as  bending  forward  or  backward, 
will  cause  pain,  if  the  appendix  is  adherent  to  the  anterior  abdom- 
inal w^all.  Bowel  distention,  by  dragging  upon  the  adhering  per- 
itoneum, will  cause  pain,  which  ceases  upon  the  passage  of  the 
bowel  contents.  Adhesions  between  the  appendix  and  the  body  of 
the  psoas  muscle  are  often  the  cause  of  the  pain  felt  by  those  suffer- 
ing from  chronic  appendicitis  when  they  attempt  to  climb  stairs. 

Distant  Pains. — Pain  in  appendicitis  is  sometimes  felt  at  a 
distance  from  the  site  of  the  appendix.  These  pains  are  due  to 
stimuli  transmitted  from  the  site  of  the  original  lesion  through 
the  nervous  system  to  nerve  collaterals.  This  stimulation  is  per- 
ceived as  pain,  and  is  felt  as  coming  from  the  area  of  distribu- 
tion of  the  nerves  originating  in  the  centers  irritated. 

The  distant  pains  may  be  classed  as  referred,  transferred,  and 
reflected. 

Referred  Pain. — Referred  pain  is  due  to  the  transmission 
of  the  stimuli  along  the  splanchnics  to  the  related  spinal  centers 
in  the  cord,  and  the  pain  seems  to  be  produced  in  the  area  of  dis- 
tribution of  the  latter.  By  a  study  of  the  figures  following, 
the  location  of  the  transferred   pains  may  be  seen.      It  is  also 


520 


THE   APPENDIX 


shown  how  irritation  to  any  division  of  the  eleventh  nerve  will 
cause  a  contraction  of  the  rectus,  particularly  the  segment  supplied 
by  the  eleventh  thoracic  nerve.  Should  the  irritation  be  strong 
enough,  the  tenth  nerve  may  also  be  irritated,  and  segments  of  the 
muscle  above  the  part  suj)plied  by  the  eleventh  may  also  be  thrown 
into  contraction.     The  figTires  also  show  how  dorsal  cutaneous  ten- 


•  Posterior     division     of 
11th  dorsal  nerve 


-Posterior     division     of 
12th  dorsal  nerve 


Fig.  108. — Areas  Supplied  by  the  Posterior  Branches  of  11th  and  12th 

Thoracic  Nerves. 

The  figure  illustrates  how  appendiceal  pain  may  be  felt  posteriorly  in  the 

distribution  areas  of  these  nerves.     (Drawing  modified  from  Toldt.) 

derness  and  lumbar  jDain  may  be  present,  the  areas  in  which  they 
are  found  being  marked  off  on  the  figure.  Pain  is,  in  some  cases, 
also  referred  to  the  vaginalis  testis  of  the  same  side,  or  it  may  be 
referred  to  the  extreme  lower  j^art  of  the  abdomen,  or  to  the  upper 
part  of  the  thigh. 

This  reference  is  through  the  first  lumbar  nerve,  which  is 
distributed  to  the  lower  abdomen  and  upper  part  of  the  thigh; 
also,  through  a  small  branch  to  the  tunica  vaginalis  testis. 

Transferred  Pain. — By  transferred  pain  is  meant  that  form 
of  pain  which  is  felt  on  the  opposite  side  or  at  a  higher  or  lower 
level  of  the  body  than  the  lesion  causing  it.    It  is  due  to  the  trans- 


VARIETIES    OF    APPENDICEAL    PAIN  521 

mission,  upward  or  downward  in  the  cord  of  the  stimulus  from 
the  point  of  origin. 

In  the  following  drawing,  modified  from  Toldt,  it  may  be  seen 
how  an  appendiceal  pain  may  be  transferred  across  the  cord  and 
be  felt  on  the  opposite  side,  the  arrows  indicating  the  origin  of 
the  stimulus  in  the  appendix,  its  conduction  to  the  thoracic  sym- 
pathetic ganglion,  and  thence  its  transference  either  to  the  ante- 
rior or  to  the  posterior  division  of  the  nerve,  the  pain  being  felt 


PAtN    l\^.  1/ 

\  V\  /^  PAIN 


PAlH  ^AIN 

Fig.  109. — Aheas  of  Pain  Referred  from  the  Appendix. 
The  arrows  indicate  the  direction  of  the  referred  sensation.     The  two  sets 
of  nerves  are  the  superficial  and  the  deep  nerves  of  the  abdominal  wall. 
At  the  point  where  they  pass  through  the  wall  and  become  superficial 
pain  is  felt.     (Drawing  modified  from  Toldt.) 

either  in  the  anterior  or  posterior  abdominal  wall.  At  its  begin- 
ning the  anterior  division  of  the  nerve  lies  in  close  relationship 
with  the  peritoneum,  so  that  any  irritation  of  the  peritoneum 
would  cause  pain,  which  would  be  felt  either  at  the  point  of  pro- 
duction, or  would  be  referred  to  the  anterior  abdominal  wall. 
Irritation  at  this  point  would  also  stimulate  the  motor  fibers 
in  the  nerve  and  segmental  contraction  of  the  rectus  would  result. 
Reflected  Pain. — The  sympathetic  nerve  supply  to  the  appen- 
dix is  derived    from  the   superior  mesenteric  plexus,  which   re- 


522 


THE   APPENDIX 


ceives  its  supply  from  the  ninth,  tenth,  eleventh,  and  possibly 
the  twelfth  dorsal  segments.  It  seems,  however,  that  the  origin  is 
chiefly  from  the  eleventh  and  twelfth  dorsal  segments,  the  eleventh 
being  the  one  most  often  involved  in  appendiceal  lesions.     In  case 


Fig.  110.  FiQ.  111. 

Figs.  110  and  HI. — Areas  of  Cutaneous  Hyperalgesia  in  Appendicitis 
Corresponding  to  the  11th  Dorsal  Area  of  Head. 

of  very  sudden  onset,  with  severe  toxemia,  reflected  pain  may  be 
absent.  It  is  also  frequently  absent  in  secondary  attacks,  because 
of  the  destruction  of  the  nerve  endings,  which  has  occurred  in 
the  primary  attack.  In  these  cases  of  reflected  pain  the  pain  is 
due  either  to  inflammation  or  to  distention  of  the  appendix. 
That  the  inflammation  alone  can  cause  it  is  well  authenticated; 
while  the  fact  that  the  reflected  pain  may  suddenly  cease  on  per- 
foration of  the  appendix  demonstrates  that  it  also  is  caused  by 
appendiceal  distention.  Figs.  112,  113,  and  114  represent  a  com- 
plete drawing  of  many  of  the  reflected  pains  felt  in  appendicitis. 
Reflected  cutaneous  hyperalgesia  is  difficult,  if  not  impossible, 
to  elicit,  should  ice  or  counter  iriitation  have  been  applied  to 


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THE    APPENDIX 


the  patient  a  short  time  previously,  because  both  reduce  the  cuta- 
neous sensibility. 

According  to  Maunsell  Moullin  (226,  p.  516),  "When  hyper- 
esthesia is  definitely  associated 
with  other  evidence  pointing  to 
an  inflammation  of  the  appen- 
dix, it  may  be  taken  as  a  clear 
indication  that  the  wall  of  the 
appendix  itself  is  involved  and 
that,  therefore,  though  the  in- 
flammation may  subside,  it  will 
in  all  probability  leave  some 
permanent  alteration  in  the  ap- 


FiG.  115. — Location  and  Radia- 
tion OF  Sympathetic  Reflected 
Pain  in  Appendicitis. 

1.  Probably  indicates  some  traction 
on  the  splenocoHc  ligament  from 
pull  on  the  colon. 

2.  Appendix  is  probably  directed  to 
left  side,  mesentery  being  derived 
from  left. 

3.  Appendix  being  directed  up  under 
the  colon. 

4.  Referred  pain  in  early  stages  of 
appendicitis. 

5.  Referred  pain  in  early  stages  of 
appendicitis. 


Fig.  116. — Location  and  Radia- 
tion OF  Sympathetic  Reflected 
Pain. 

1.  Pain  in  this  case  was  referred  to 
the  sacroiliac  synchondrosis. 

2.  Pain  was  present  over  the  sacro- 
sciatic  notch  and  radiated  down 
the  leg.  Appendix  was  found 
lying  across  the  psoas  muscle, 
being  entirely  retroperitoneal. 
No  mesoappendix  was  present 
except  about  3^  inch  at  extreme 
tip  of  the  appendix. 

3.  Same  as  3  in  Fig.  115. 

4.  Pain  over  left  kidney  due  to 
gangrenous  appendix,  no  kidney 
lesion. 


VARIETIES    OF    APPENDICEAL    PAIN 


525 


pendix,  which  later  will  necessitate  operation.  Sudden  cessation 
of  the  hyperesthesia  without  at  the  same  time  any  improvement 
in  the  other  symptoms  often  indicates  that  the  appendix  has  be- 
come gangrenous." 

Figaires  115,  116  and  llY  show  the  location  and  radiation  of 
sym.pathetic  reflected  pain. 


Fig.  117. — Areas  of  Hyperalgesia  in  the  Uth  Dorsal  Visceral  Seg- 
ment Due  to  Appendicitis  of  the  Catarrhal  Type. 

The  pain  of  appendicitis  is  well  illustrated  in  the  accompany- 
ing case,  in  which  the  acute  pain,  present  in  the  right  side,  was 
associated  with  a  well-marked  hyperalgesia  over  the  same  area.  As 
the  subjective  pain  decreased,  the  hyperalgesia  also  decreased, 
so  that  when  the  subjective  pain  was  gone  the  latter  also  was 
entirely  absent.  Deep  pressure  over  the  appendix  area  still 
caused  pain,  but  no  hyperalgesia,  so  that  the  patient  was  tender 
but  not  hyperalgesic.  This  illustrates  tho  independence  of  the  two 
symptoms.  On  operation  the  appendix  was  found  enlarged,  swol- 
len, and  very  much  inflamed.  It  extended  along  the  right  side  of 
the  abdomen,  running  up  in  the  direction  of  the  liver.  Adhesions 
were  not  present. 

The  following  photographs  are  of  a  boy  eight  years  of  age. 


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VARIETIES    OF    APPENDICEAL    PAIN  527 

who  complained  of  severe  pain  in  the  abdomen.  Examination 
showed  the  following  area  of  tenderness  (see  Fig.  118)  :  the 
shaded  portion,  which  indicates  the  area  of  sensitiveness  to  pain, 
such  as  to  pinching;  the  cross-shaded  portion,  which  indicates  the 
area  of  sensitiveness  to  touch,  and  the  dark  spots,  which  indicate 
points  of  maximal  tenderness  (to  touch),  which  were  produced 
by  deep  pressure.  The  circle  around  the  umbilicus  indicates  the 
region  to  which  he  referred  his  pain. 

At  first  there  was  thought  to  be  a  possibility  of  malingering 
in  this  case,  as  on  a  second  examination  the  area  of  sensitiveness 
had  moved  slightly,  and  on  a  third  examination  the  area  of 
cutaneous  hyperalgesia  was  much  smaller  than  on  the  first  exami- 
nation, being  about  one-half  inch  smaller  at  all  points.  This  idea 
was  dismissed  later,  as  it  was  observed  in  several  cases  that  the 
area  of  hyperalgesia  may  change  according  to  the  change  in  the 
position  of  the  patient,  and  definitely  according  to  that  change ; 
also  that  it  becomes  smaller  as  the  disease  progresses  toward  a  cure. 

Pain  on  the  left  side  in  appendicitis  may,  in  some  cases,  be 
due  to  the  position  of  the  appendix  on  that  side.  Below  are  a 
few  of  the  positions  which  the  appendix  may  take,  owing  to  a 
faulty  rotation  (Annals  Surg.,  July,  1908,  p.  137). 

Left-sided  pain  may  also  be  due,  in  some  cases,  to  an  inflamed 
appendix  situated  in  the  pelvis  on  the  left  side. 

Sympathetic  pain,  such  as  headache  or  generalized  aching,  so 
common  in  appendicitis,  is  the  result  of  the  action  of  the  toxins 
(produced  in  appendicitis)  on  the  centers  supplying  the  areas  in 
which  the  pain  is  present. 

In  connection  with  aberrant  pains  in  appendiceal  inflamma- 
tory states,  it  is  a  fact  that,  in  many  of  these  so-called  pains,  there 
is  a  separate  anatomical  basis  for  the  pain-sensation.  Appendicitis 
and  colitis,  says  Lockwood  (127b),  are  often  closely  related,  and 
in  those  cases  which  had  pain  over  various  parts  of  the  colon 
there  was  also  associated  a  mucous  colitis,  which  was  the  underly- 
ing cause  of  this  most  prominent  and  distressing  symptom. 

In  regard  to  involvement  of  the  colon  in  appendicitis  and  its 
relationship  to  pain-production,  the  reader  is  referred  to  the  sec- 


o 

3.2 -2 


528 


TENDERNESS   IN   APPENDICITIS  529 

tion  on  diseases  of  the  colon,  where  the  pain  resulting  from  colonic 
involvement  is  carefully  reviewed. 

In  this  connection  it  is  well,  also,  to  recall  the  fact  that  epi- 
gastric pain,  occurring  at  some  late  stage  of  appendicitis,  or  dur- 
ing the  course  of  the  disease  after  the  pain  has  been  localized 
in  the  right  iliac  fossa,  is  almost  pathognomonic  of  a  peritonitis 
(W.  D.  Stanton). 

Tenderness  in  Appendicitis. — The  following  are  Robinson's 
(265,  pp.  414-415)  conclusions  in  regard  to  the  presence  of  super- 
ficial tenderness  in  disease  of  the  appendix: 

"In  disease  of  the  vermiform  appendix,  or  in  disease  originat- 
ing therein,  cutaneous  tenderness  is  sometimes  present,  most  com- 
monly in  the  skin  innervated  from  the  eleventh  dorsal  segment 
of  the  spinal  cord,  but  also  sometimes  in  the  territory  of  the 
ninth,  tenth,  and  twelfth  dorsal,  and  possibly  the  eighth  dorsal 
and  first  lumbar  segments. 

"According  to  Sherren  (26G),  there  are  three  chief  forms  of 
cutaneous  tenderness.  The  first  is  in  the  form  of  a  broad  band, 
extending  from  about  the  level  of  the  first  lumbar  vertebra  around 
the  anterior  surface  of  the  body,  having  a  general  downward 
direction,  and  ending  below  the  umbilicus.  Its  lower  edge  rides 
over  the  crest  of  the  ilium.  The  entire  band  closely  corresponds 
to  the  area  of  sensory  distribution  of  the  eleventh  dorsal  segment. 
The  second  area  is  triangular,  its  upper  boundary  being  on  a 
level  with  the  umbilicus,  its  apex  over  the  crest  of  the  ilium,  and 
its  base  on  the  right  side,  toward  the  median  line  of  the  body. 
The  third  area  is  found  about  the  middle  of  a  line  joining  the 
umbilicus  and  the  anterior  superior  spine.  A  corresponding  area 
is  on  the  back  just  above  the  iliac  crest. 

"A  patient  displaying  an  area  of  superficial  tenderness  of 
one  of  these  three  defined  varieties  is,  in  the  gTeat  majority  of 
cases,  suffering  from  appendicitis.  ]^evertheless,  many  other 
diseases  may  resemble  appendicitis  in  this  respect ;  for  instance, 
renal  colic,  perforated  gastric  ulcer,  intestinal  colic  and  perime- 
tritis. 

.  "Infiammation  of  nerve  trunks  is  not  the  cause  of  this  symp- 


530  THE   APPENDIX 

torn,  for  the  latter  may  occur  in  skin  supplied  by  the  post-primary 
divisions  of  the  spinal  nerves.  There  is  little  evidence  as  to  the 
immediate  cause  of  this  reflex  tenderness,  but  it  is  probably  due 
to  irritation  of  the  afferent  nerves  from  the  appendix.  The  irri- 
tant is  possibly,  in  some  cases,  tension ;  in  others,  it  is  almost 
certainly  something  different.  The  symptom  is  found  in  a 
minority  only  of  the  cases  of  appendicitis  seen  in  hospital  prac- 
tice. It  may,  while  a  case  is  under  observation,  vary  in  charac- 
ter or  disappear  altogether.  During  the  progress  of  an  attack,  it 
may  appear  in  a  patient  in  whom  it  has  not  originally  been 
present. 

"Cutaneous  tenderness  is  found  as  frequently  in  subsequent 
as  in  first  attacks  of  appendicitis.  It  may  persist  long  after  all 
other  signs  of  the  disease  have  disappeared. 

''The  prognostic  and  therapeutic  significance  of  cutaneous 
tenderness,  in  cases  of  appendicitis,  is  slight.  It  is  somewhat 
less  often  found  in  cases  of  abscess  than  in  other  cases.  When 
the  symptom  and  abscess  coexist,  the  abscess  is  usually  only  a 
beginning  process. 

"Cases  of  widespread  peritonitis,  set  up  by  appendicitis,  may 
display  large  areas  of  cutaneous  tenderness  over  the  right  side, 
or  over  the  whole  of  the  abdomen." 

Tenderness  as  a  Symptom  in  Appendicitis. — In  two  hundred 
and  forty-seven  cases,  reported  by  Sherren  (267),  and  Robinson 
(265),  hyperalgesia  was  found  in  66,  or  26.7  per  cent.:  sixteen 
times  as  a  complete  band ;  thirty-two  times  as  a  triangle ;  four- 
teen times  as  a  circular  spot;  and  three  times  as  a  large,  irregu- 
lar area. 

Sherren  makes  the  statement  that  tenderness  may  be  absent 
in  attacks  after  the  first,  if  the  first  attack  was  of  sufficient  sever- 
ity to  destroy  nerve  tissue  in  the  wall  of  the  appendix  (265,  p. 
398).  The  number  of  cases  examined  by  Robinson  was  one  hun- 
dred and  twenty -three,  and  the  proportion  of  positive  and  nega- 
tive cases  was  21.1  and  78.9;  but,  as  Robinson  says,  this  does 
not  invalidate  Sherren 's  statement,  for  the  occurrence  of  previous 
attacks  may  dispose  the  sufferer  to  superficial  tenderness,  and  so 


TENDERNESS    IN    APPENDICITIS  531 

make  up  for  the  cases  in  which  nerve  tissue  has  been  destroyed. 
He  further  says  that  the  cases  he  has  seen  are  the  severe  and 
neglected  ones;  and  that  in  the  milder  cases,  which  are  seen  in 
private  practice,  the  presence  of  pain  is  more  common. 

During  its  disappearance,  as  the  other  symptoms  of  the  dis- 
ease clear  up,  the  areas  of  hyperesthesia  assume  many  irregular 
and  migratory  shapes. 

Another  conclusion  of  Sherren's  is  that  the  disappearance  of 
cutaneous  hyperalgesia,  without  improvement  in  the  general  con- 
dition of  the  patient,  is  a  sign  of  perforation  or  gangrene,  and 
should  be  the  sign  for  immediate  operation.  Bennett  (142,  p. 
1005)  questions  the  entire  accuracy  of  this  statement. 

According  to  Sherren,  also  (265,  p.  399),  the  presence  of 
cutaneous  tenderness  is  no  contraindication  for  operation.  Ab- 
scess may  form  and  general  peritonitis  develop  while  it  is  pres- 
ent. Of  twenty-six  positive  cases,  Robinson  found  abscess  in 
eleven ;  gangrene  in  nine ;  perforation  in  seven ;  and  general  peri- 
tonitis in  three. 

"However,  absence  of  cutaneous  hyperalgesia  is  of  gTeat  im- 
portance. Absence  of  cutaneous  hyperalgesia  in  a  patient  coming 
under  observation  early  in  the  first  attack  of  appendicitis  is  a 
sign  of  gangrene  of  the  appendix,  unless  the  case  is  obviously  mild 
and  is  getting  well  rapidly.  (Robinson  is  in  accord  with  this  state- 
ment.) Cutaneous  tenderness,  as  a  rule,  is  absent  in  cases 
of  abscess  of  the  appendix.  (This  is  true  in  two  out  of  three 
cases.)  The  age  of  the  patient  and  the  position  of  the  appendix 
have  no  influence  on  the  cutaneous  hyperalgesia.  Cutaneous 
hyperalgesia  is  occasionally  of  use  in  the  diagnosis  of  appendi- 
citis. Cutaneous  hyperalgesia,  in  the  area  which  is  associated 
with  appendiceal  disease,  generally  is  an  indication  of  appendi- 
ceal involvement,  though  of  necessity  it  is  not  a  pathognomonic 
sign,  for  it  has  also  been  noted  in  other  conditions,  such  as  per- 
forated duodenal  ulcer,  intestinal  colic,  and  peritonitis.  In  a  case 
of  perimetritis  the  area  of  hyperalgesia  was  in  the  form  of  the 
small  circular  patch,  already  described.  This  may  be  the  same 
as  Morris's  point  or  area  of  tenderness"  (Sherren,  265). 


532  THE   APPENDIX 

Varieties  of  Tenderness. — In  acute  appendicitis  two  varieties 
of  tenderness  are  present:  (1)  tenderness  to  superficial  irritation 
in  which  over  certain  areas  light  pressure,  as  the  drawing  of  the 
point  of  a  pin  over  the  surface,  produces  pain.  These  areas  of 
tenderness  are  but  reflexes  from  the  viscera,  and  correspond  to  the 
zones  Head  has  worked  out  for  the  eleventh  and  twelfth  dorsal 
segments.  Recently  Elsberg,  of  New^  York,  has  confirmed  to  a 
large  extent  the  earlier  observations  of  Head.  The  points  of  most 
exquisite  tenderness  are  but  the  maximal  tender  points  of  Head. 

Robinson  says  (265,  p.  392)  that  it  is  "remarkable,  in  all 
definite  cases  of  appendicitis,  how  definite  is  the  line  of  tender- 
ness between  the  tender  and  non-tender  areas." 

This  superficial  tenderness  generally  occurs  during  the  first 
attack,  which  may  be  a  very  mild  one.  In  some  cases  the  discom- 
fort may  be  the  result  of  a  mild  inflammation  of  the  mucosa,  while 
in  others  for  the  pain  production  it  is  necessary  that  the  perito- 
neum be  involved. 

Sherren  (267,  625,  p.  390)  thinks  that  a  suj)erficial  tenderness 
is  due  to  stimulation  of  nerves  within  the  appendix,  the  result  of 
intralumenary  tension.  This  statement  is  disputed  by  Robinson, 
who  says  that  "inflammation  and  the  products  of  inflammation 
are  capable  of  acting  just  as  well."  He  says  further,  that  "tension 
may  exist  without  tenderness,  tenderness  may  be  present  without 
tension,  and  the  mere  destruction  of  the  afferent  nerve  fibers  or 
endings  does  not  seem  to  abolish  the  symptom  in  all  cases,  any 
more  than  tension  on  them  of  necessity  produces  it." 

(2)  Tenderness  on  deep  pressure  is  always  an  indication  that 
the  inflammation  has  spread  to  the  peritoneum.  It  is  generally, 
also,  an  indication  of  an  abscess  formation,  in  which  the  parietal 
peritoneum  takes  part.  Should  the  peritoneal  involvement  be  con- 
siderable, subjective  pain  will  also  be  associated  with  the  tender- 
ness, and  the  muscles  over  the  painful  area  will  be  contracted. 
This  contraction  is  due  to  the  beneficent  reflex  of  Hilton,  in  which 
the  muscles  over  an  (inflamed)  area  supplied  by  the  same  nerve  or 
nerves  contract. 

In  chronic  appendicitis  the  tenderness  is  due  chiefly  to  the 


TENDERNESS    IN    APPENDICITIS  533 

adhesions  which  are  present.  In  this  condition  palpation  of  cer- 
tain areas  seems  to  be  particularly  painful.  The  increased  pain 
is  due  to  the  much  greater  pull  or  drag  upon  the  band  of  adhe- 
sions, resulting  from  the  palpation.  Peristalsis  of  the  bowel  will 
also  cause  pain.  In  examining  patients  for  cutaneous  tenderness 
see  that  no  poultices,  compresses,  fomentations,  or  ice  have  pre- 
viously been  used. 

Tenderness  may  also  be  found : 

(a)  In  the  lumbar  regions  when  the  appendix  is  retrocecal. 
Here  the  tenderness  is  probably  due  to  direct  pressure  exerted  by 
the  cecum  upon  the  appendix. 

(&)  Vaginal  palpation  may  produce  pain  if  the  appendix  lies 
in  the  pelvic  cavity.  It  is  very  hard  in  this  condition  to  distin- 
guish by  palpation  an  appendix  from  an  inflamed  fallopian  tube. 
However,  the  other  signs  and  symptoms  present  in  appendicitis 
aid  in  the  diagnosis.  Should  the  appendix  be  in  the  pelvis,  defe- 
cation and  micturition,  due  to  the  traction  exerted  upon  the  ap- 
pendix by  the  adhesions  which  bind  it  to  the  bladder  or  to  the 
rectum,  may  be  painful.  Pain  may  also  be  present  on  bending 
and  straightening  of  the  thigh.  When  this  is  the  case,  the  appen- 
dix lies  on  and  is  adherent  to  the  psoas  muscle,  and  the  pain  is  due 
to  pressure  and  traction,  the  result  of  movement  and  contraction  of 
this  muscle. 

(c)  Transabdominal  tenderness, — In  many  cases  a  typical  ap- 
pendiceal pain  can  be  produced  in  the  area  of  appendiceal  reflec- 
tion by  making  pressure  over  the  colon  at  the  corresponding  point 
on  the  left  side.  This  area  corresponds  rather  closely  with  Mor- 
ris's point  of  tenderness  in  tubal  and  ovarian  disease.  Eovsing 
(Ref.  190)  makes  no  mention,  however,  of  the  presence  of  tubal  or 
ovarian  disease,  but  states  that  in  more  than  one  hundred  cases 
it  was  never  found  unless  there  was  some  affection  of  the  cecum 
or  appendix.^ 

^  Dieulaf  oy  had  first  indicated  the  contraction  of  the  abdominal  musclea 
as  an  indicator  of  intraabdominal  inflammatory  states — the  so-called  muscular 
defense,  defense  musculaire.  This  symptom  is  a  good  indication  that  gan- 
grene or  perforation,  with  beginning  free  or  circumscribed  peritonitis,  has  al- 
ready taken  place. 


534  THE   APPENDIX 

Special  Points  of  Tenderness. — The  presence  of  pain  at  Mc- 
Burney's  point  lias  long  been  regarded  as  symptomatic  of  appen- 
diceal involvement.  This  point  is  situated  one  and  one-half 
inches  from  the  anterior  superior  spine,  on  a  line  running  from 
the  anterior  superior  spine  to  the  umbilicus.  Pressure  at  this 
spot  has  been  held  to  be  iiroductive  of  pain  in  diseases  of  the 
appendix.  This  area  of  pain  is  not  constant,  but  it  may  be  said 
that  in  general  its  presence  indicates  appendiceal  involvement, 
while  its  absence  is  of  no  significance.  In  no  case  is  its  presence 
in  any  way  connected  with  the  location  of  the  appendix.  In  fact, 
Lanz  has  shown  that,  as  a  rule,  the  appendix  is  some  distance 
away  from  the  painful  spot,  and  generally  is  below  it. 

Morris,  of  !New  York,  has  described  a  point  of  tenderness 
about  one  and  one-half  inches  from  the  umbilicus,  on  a  line  ex- 
tending from  the  navel  to  the  anterior  superior  spine  of  the  ilium. 

In  reference  to  this  point  and  its  diagnostic  value,  the  con- 
clusions of  Hubbard  are  pertinent.  He  says  that,  "this  tenderness 
is  due  to  a  tender  lymjDh-gland,  which  has  drained  the  region  of 
the  appendix,  and  there  is  nothing  absolutely  diagnostic  in  its 
presence.  In  acute  appendicitis  tenderness  at  Morris's  point 
is  of  less  importance  than  the  symptoms  caused  by  the  appendix 
itself.  However,  in  chronic  appendicitis  tenderness  at  Morris's 
point  may  be  of  distinct  diagnostic  value.      Tenderness  at  this 

Perman  (80b)  had  in  a  report  of  appendix  cases  (appearing  in  the  Hy- 
geia  for  1904,  p.  797)  spoken  of  right-sided  pain  produced  by  pressure  in  the 
left  iliac  region  in  a  case  of  appendicitis.  At  the  present  time  this  symptom- 
complex  is  known  as  Rovsing's  sign.  The  best  way  to  obtain  the  pain  is  to 
lightly  tap  the  abdomen  on  the  left  side,  while  the  patient  breathes  quietly 
and  relaxes  the  abdominal  muscles. 

Perman  argues  with  Hofman  and  Hausman  that  the  pain  is  not  due  to  the 
stretching  of  the  cecum  due  to  the  pushing  up  of  the  colon  contents,  but  rather 
to  the  pressure  carried  directly  from  the  palpated  to  the  inflamed  area.  If  the 
sign  is  present,  in  chronic  or  in  interval  attacks  of  appendicitis,  it  is  due  to 
adhesions.  When  present  in  acute  attacks,  the  appendicitis  is  not  simply  a 
catarrhal  form,  but  is  a  pathological  case  of  the  most  severe  kind,  either  a 
beginning  phlegmonous  infiltration  or  gangrene  with  threatening  perforation. 
The  sign  may  also  be  present  in  salpingitis.  In  a  few  of  those  cases  and  in 
pelvic  peritonitis  Perman  (80b)  has  observed  it. 

Lauenstein  (53b)  also  doubts  the  value  of  this  sign,  and  believes  that 
Eovsing  also  will  in  the  future  change  his  mind  regarding  its  absolute  sig- 
nificance. 


SYMPTOMS  ASSOCIATED  WITH  PAIN  IN  APPENDICITIS     535 

point,  even  though  the  only  physical  sign,  by  the  rule  of  chance, 
makes  the  diagnosis  of  appendicitis  probable.  When  combined 
with  tenderness  at  McBurney's  point  the  diagnosis  becomes  more 
certain.  Its  absence  does  not  rule  out  appendicitis,  and  its  pres- 
ence does  not  make  the  diagnosis  of  appendicitis  absolute,  for  it 
may  occur  in  other  conditions  besides  appendicitis.  The  point 
has  by  no  means  the  importance  given  it  by  Dr.  Morris."  (See 
areas  of  reflex  tenderness.  Head's  zones,  in  appendicitis.)  In 
hernia  of  the  appendix  the  pain  is  more  or  less  diffused  around 
the  umbilicus,  or  lies  in  the  lower  abdomen.  It  is  described  as 
colicky  in  character,  sometimes  as  a  dragging  sensation  which  in 
felt  in  the  right  iliac  fossa.  (See  the  relationship  between  the 
dragging  and  the  location  of  the  pain,  which  is  the  same  as  in  an 
early  case  of  appendiceal  inflammation.) 

Symptoms  Associated  with  Pain  Production  in  Appendicitis. 
— Rigidity  of  the  right  rectus  is  an  almost  invariable  accompani- 
ment of  appendiceal  inflammation.  It  is  most  marked  in  the 
muscular  segments  located  immediately  above  the  appendix. 
Should  rigidity  suddenly  increase,  and  become  general  over  the 
entire  abdomen,  with  a  sudden  increase  of  pain,  it  is  an  indica- 
tion of  a  rupture  of  the  appendix,  or  of  a  sudden  spread  of  the 
inflammation,  so  that  a  generalized  peritonitis  has  resulted. 

Constipation  is  one  of  the  associated  symptoms  of  appendi- 
citis. It  is  due  to  a  reflex  arising  from  the  inflamed  organ.  Often 
the  reflex  peristalsis  can  be  aroused  in  a  normal  intestine  by  the 
pressure  of  the  bowl  of  the  stethoscope.  A  weak  or  absent  peri- 
stalsis is  an  indication  of  the  spread  of  exacerbation  of  the  inflam- 
mation. 

Motion  is  generally  interfered  with;  climbing  the  stairs  is  a 
source  of  pain,  especially  when  the  appendix  lies  upon  the  psoas 
muscle.  The  reason  of  the  much  greater  pain  when  the  patient  is 
walking  or  climbing  stairs  is  that,  in  these  conditions,  there  is  a 
concomitant  contraction  of  the  psoas  muscle  and  the  abdominal 
wall  muscles,  and  the  appendix,  caught  between  the  two,  is  sub- 
ject to  considerable  pressure.  Often  the  first  indication  of  peri- 
toneal pain  has  occurred  during  the  drawing  on  of  the  shoes. 


536  THE   APPENDIX 

Posture. — In  appendicitis  the  patient  usually  assumes  a  re- 
cumbent dorsal  posture,  with  one  limb,  usually  the  right,  drawn 
up,  and  in  some  cases  lies  with  the  right  limb  thrown  over  the 
left.  In  many,  especially  after  an  abscess  formation,  or  when 
adhesions  are  present  and  the  bowel  segments  are  bound  to- 
gether, a  left  lateral  posture  is  very  painful ;  this  is  due  to  the 
drag  and  pull  upon  the  adhesions  by  the  weight  of  the  bowel  in 
this  position.  It  is  common  for  patients  with  appendicitis,  when 
walking,  to  bend  the  body  forward  and  step  lightly. 

Jarring,  such  as  occurs  in  running  and  jumping,  frequently 
causes  pain.  x\ny  spasmodic  movement  of  the  diaphragm,  such 
as  takes  place  in  vomiting,  coughing,  and  sneezing,  also  gives 
rise  to  pain.  Percussion  of  the  abdomen  also  produces  it,  and  it 
is  claimed  by  Schmidt  that  often  by  this  means  the  delimitation 
of  pain  is  more  accurate  than  by  any  other.  The  pain  is  greater 
when  percussion  is  made  directly  over  the  median  line  than  when 
it  is  made  to  either  side,  because  here  the  protective  action  of 
the  Muscles  to  the  abdominal  viscera  is  lacking. 

During  appendicitis  pressure  on  the  abdomen  is  very  painful, 
particularly  so  if  to  the  appendicitis  peritonitis  has  been  added. 
When  this  ensues  vomiting  generally  occurs.  In  some  cases  of 
appendicitis,  pain  can  be  produced  by  palpation  upon  the  opposite 
side  of  the  abdomen.  Another  means  of  diagnosing  appendicitis 
is  to  distend  the  colon  with  gas.  As  soon  as  the  gaseous  distention 
reaches  the  appendiceal  region,  pain  is  produced  by  disturbance 
of  the  cecal  relationship  if  peritonitis  is  present,  or  by  appendi- 
ceal distention  should  only  the  appendix  be  involved.  However, 
this  is  a  dangerous  procedure,  and  should  be  used,  if  at  all,  only 
in  chronic  cases. 

Sudden  increase  in  the  sensibility  to  pressure  is  indicative  of 
extension  of  the  inflammation.  The  sensibility  may  be  so  great 
that  even  the  weight  of  the  bed-clothes  is  unbearable.  In  some 
cases  distention  of  the  bowel  may  also  cause  great  sensitiveness  to 
pressure.  Pain  on  pressure  under  the  costal  margin  is  chiefly 
of  peritoneal  origin. 

The  pain  of  appendicitis,  in  many  cases,  seems  to  be  induced 


DIFFERENTIAL    DIAGNOSIS  537 

bj  peristalsis.  Many  a  sufferer  has  been  aroused  in  the  middle 
of  the  night  by  the  most  severe  cramps,  Avhich  the  later  progress 
of  the  case  i^roves  to  be  of  appendiceal  origin.  These  come  on  at 
the  time  intestinal  peristalsis  is  most  active,  that  is,  from  five  to 
seven  hours  after  eating.  In  some  cases  the  ingestion  of  cold 
food  or  drinks  will  incite  active  peristalsis  and  thus  cause  pain 
(Schmidt). 

Differential  Diagnosis.  — The  pain  of  appendicitis  should  be 
diagnosed  from :  colitis,  which  generally  is  not  productive  of 
pain;  but  if  it  is,  the  accompanying  diarrhea,  with  its  content 
of  mucus,  is  sufficient  for  a  diagnosis;  intussusception,  in  case  of 
tumor  formation.  It  is  very  difficult,  in  many  cases,  particularly 
Avhen  pain  is  very  severe,  to  decide  whether  the  condition  is  one 
of  appendicitis  or  intussusception,  especially  so  should  the  condi- 
tion be  associated  with  vomiting  and  constipation. 

Gall-hladder  and  gall-stone  colic  pain  may  be  diagnosed  by 
the  higher  area  of  cutaneous  hyperalgesia ;  also  by  the  area  of 
local  tenderness  present  in  these  conditions.  Typhoid  fever,  espe- 
cially when  it  is  of  sudden  onset  and  commences  as  an  acute  ab- 
dominal pain,  has  on  more  than  one  occasion  been  mistaken  for 
appendicitis,  and  the  patient  has  been  operated  on  under  that  mis- 
taken diagnosis,  in  some  cases  with  disastrous  results.  Generally, 
in  these  diseases  (typhoid),  the  pain,  while  severe,  is  still  bearable, 
and,  as  a  rule,  there  is  not  present  any  considerable  amount  of 
abdominal  rigidity.  The  temperature  also  is  of  the  ordinary 
typhoidal  type,  high  in  the  evening  and  low  in  the  morning,  while 
in  appendicitis  it  is  more  constant.  The  blood  count  in  typhoid  is 
also  low  in  leukocytes,  while  generally,  in  appendicitis,  it  is  high. 
Should  the  pain  occur  later  in  the  disease  (about  the  third  week), 
and  be  associated  with  abdominal  rigidity,  perforation  should  be 
sought  and  careful  inquiry  should  be  made  as  to  the  type  and 
character  of  the  pain.  A  constant,  spreading  pain,  very  sharp  and 
severe,  generally  indicates  a  spreading  peritonitis. 

Ovarian  and  Tubal  Disease. — In  the  diagnosis  of  appendi- 
citis from  right  salpingitis  or  oophoritis,  the  presence  on  the  right 
side  of  tenderness,  which  is   increased   and,   at   the   same  time. 


538  THE    APPENDIX 

is  associated  with  subjective  pain  at  the  menstrual  period,  is  a 
criterion  of  worth.  In  those  conditions  which  closely  simulate 
both  appendicitis  and  ovarian  or  tubal  involvement,  it  must  not 
be  forgotten  that  either  or  all  may  simultaneously  exist,  and  that, 
if  they  do  so,  symptoms  of  one  or  of  all  three  may  be  present.  If 
all  of  these  organs  are  acutely  inflamed,  adhesions  will  remain 
after  the  inflammation  subsides,  and  these  adhesions  will  be  a 
potent  cause  for  pain  production  in  the  future.  A  point  of  some 
importance  to  remember  is  that  pains  due  to  involvement  of  the 
genitalia  are  never,  or  very  seldom,  influenced  by  the  ingestion  of 
food.  Vaginal  examination  may  help  to  clear  the  diagnosis, 
though  when  the  appendix  is  in  the  pelvis  it  may  be  difiicult  to 
differentiate  appendicitis  from  tubal  disease.. 

Hydi'oneplirosis  has  been  mistaken  for  appendicitis,  but  the 
urinary  symptoms  of  the  former,  with  the  history  of  the  disease, 
should  render  easy  the  diagnosis. 

Ureteral  calculus  has  a  pain  that  is  very  sharp  and  severe, 
and  soon  after  the  cessation  of  the  pain,  or,  if  the  attack  is  pro- 
longed, during  it,  blood  may  be  present  in  the  urine. 

Sciatica  could  hardly  be  mistaken  for  appendicitis,  though 
appendicitis  with  referred  or  reflex  pain  down  the  back  of  the 
thigh  has  been  mistaken  for  sciatica. 

Carcinoma  of  the  cecum  is  a  condition  associated  with  tumor, 
emaciation,  and  signs  of  a  gradually  increasing  intestinal  obstruc- 
tion. 

Lumbago  can  hardly  be  confused  with  appendicitis,  even 
in  those  cases  in  which  appendiceal  referred  pain  is  felt  in  the 
back. 

Peritonitis  has  been  mistaken  for  aiDpendicitis.  This  can 
hardly  happen  with  a  careful  observer,  for  the  bilateral  and  deep 
tenderness,  generalized,  with  tenderness  on  vaginal  and  rectal  ex- 
amination cannot  but  be  interpreted  as  due  to  peritoneal 
involvement.  Tuberculous  peritonitis,  in  which  the  lesions  are 
confined  to  the  cecum,  is  very  difiicult  to  diagnose  from  chronic 
appendicitis.  The  more  chronic  course,  the  tuberculin  reaction, 
the  presence  of  a  focus  of  tuberculosis  elsewhere,  the  very  slow 


DIFFERENTIAL    DIAGNOSIS  539 

onset,  with  no  history  of  an  acute  attack,  are  diagnostic  criteria 
of  very  great  value. 

Extrauterine  pregnancy  has  also  been  mistaken  for  appendi- 
citis, but  the  presence  of  fluid  in  the  cul-de-sac  of  Douglas,  the 
history  of  pregnancy,  the  presence  of  anemia,  and  the  passage  of 
some  bloody  discharge  from  the  uterus  help  in  the  diagnosis. 

Erythema  exudativmn  multiforme  sometimes  causes  a  pain 
resembling  ajDpendiceal  crises. 

Sagging  loops  of  intestine,  or  omentum,  by  pressure  upon  the 
external  abdominal  ring,  jDroduce  j^ains  that  closely  resemble  those 
experienced  in  chronic  appendicitis. 

Cheinisse  (454,  pp.  1-12)  describes  a  condition  which  is  fre- 
quently associated  with  syphilis,  influenza,  or  hysteria,  in  which 
there  is  considerable  pain  around  McBurney's  point.  The  diag- 
nostic differentiating  points  are :  the  absence  of  leukocytosis, 
fever,  and  raj)id  pulse.  Painful  points  may  also  exist  at  the  exit 
of  certain  nerves.  The  abdominal  wall,  also,  is  not  rigid,  and  the 
pain,  as  a  rule,  is  not  confined  to  one  defiiiite  location.  A  variable 
tumor  is  felt. 


CHAPTER  XXVI 

THE  LIVER,  GALL  BLADDER  AND  DUCTS 

GENERAL  CONSIDERATIONS 

The  liver  is  the  largest  gland  in  the  body.  It  is  subject  to 
diseases  similar  to  those  of  other  glands,  and  also  to  additional 
disturbances,  functional  and  anatomical,  due  to  its  different 
structure  and  function  and  to  its  intimate  relationship  with  the 
digestive  apparatus. 

The  painful  disorders  affecting  the  liver  as  a  glandular  organ 
are  congestion,  inflammation,  adhesion,  and  displacement. 

The  painful  disorders  affecting  the  liver  and  gall-bladder  be- 
cause of  modified  structure  are  inflammation  of  the  gall  blad- 
der, inflammation  of  the  ducts,  obstruction  of  the  ducts  by  foreign 
bodies  or  new  growths,  adhesions,  etc. 

Nerve  Supply. — The  nerve  supply  to  the  liver  is  sympathetic. 
It  does  not,  as  many  have  thought,  derive  through  its  convex  sur- 
face a  partial  supply  from  the  branches  of  the  intercostal  nerves 
distributed  to  the  dome  of  the  diaphragm,  nor  does  it  have  any 
connection  with  the  phrenic,  Ranstrom  being  unable  to  trace  a 
single  branch  of  the  phrenic  nerve  through  the  suspensorium  liga- 
ment to  the  capside  of  the  liver,  also  no  twigs  from  the  intercostals 
could  be  found  extending  to  the  surface  of  the  liver.  The  sympa- 
thetic fibers  are  derived  mostly  from  adjacent  sympathetic  plexi 
and  ganglia  (coeliacum,  etc.),  which  in  turn  are  connected  with 
well-defined  segments  of  the  cord.  The  cord  segments  involved  in 
diseases  of  the  liver  proper  are  the  eighth  and  ninth,  and  some- 
times the  tenth  dorsal,  while  the  fifth,  sixth  and  seventh  dorsal 
segments  are  involved  in  disease  of  the  gall  bladder.  The  outlines 
540 


GENERAL   CONSIDERATIONS 


541 


of  the   segments,  with  their  maximal  points  of  tenderness,   are 
shown  in  the  annexed  figures.     The  maximal  points  of  tenderness 


Fig.  122. — Abeas  of  Referred 
Pain  in  Liver  Disease:  An- 
terior View.  (According  to 
Head.) 


Fig.  123. — Areas  of  Referred 
Pain  in  Liver  Disease:  Pos- 
terior View.  (According  to 
Head.) 


of  these  zones  closely  correspond  with  the  areas  in  which  pain  and 
tenderness  are  felt  in  diseases  of  the  liver  and  gall  gladder. 

The  vagus  also  assists  in  the  liver  innervation  (Edgeworth). 
In  some  cases  of  common  duct  disease,  especially  when  the  area 
near  the  junction  of  the  hepatic  and  cystic  duct  is  involved,  the 
pain-producing  stimulus  is  carried  through  the  branch  from  the 
adjacent  sympathetic  plexus  to  the  left  vagus,  and  thence  to  the 
fourth  and  sixth  dorsal  segments,  from  whence  it  is  reflected  to 
the  chest  wall  in  the  distribution  area  of  these  segments.  This 
explains  why  pain  is  sometimes  felt  in  the  left  anterior  wall 
of  the  chest,  at  about  the  level  of  the  fourth  or  fifth  costal 
cartilage. 

The  accompanying  sketch  (Fig.  125)  shows  how  pain  irrita- 
tive sensation  may  be  carried  from  the  vicinity  of  the  hepatic 
duct  to  the  vagus,  and  thence  be  propagated  through  the  sixth  or 
fourth  ganglia  of  the  sympathetic  to  the  adjacent  cord  section, 


542 


THE   LIVER,    GALL   BLADDER   AND    DUCTS 


from  whence  it  is  carried  to  the  brain,  and  is  felt  as  coming  from 
the  somatic  distribution  area  of  these  segments.  The  maximal 
points  of  tenderness  in  these  segments  are  shown  in  Figs.  122 
and  123. 

Pain  in  the  right  shoulder  in  liver  disease  is  transferred 
through  the  right  phrenic.  This  happens  when  the  diaphragm  is 
involved  by  a  lymphangitis  spreading  from 
an  inflamed  liver  or  gall  bladder.  The  draw- 
ing on  the  next  page  shows  the  paths  of  com- 
munication between  the  liver  and  the  cord. 

The  liver  itself  is  not  very  sensitive  to 
pain-producing  stimuli,  for  Lennander  was 
able  to  apply  a  strong  faradic  or  galvanic 
current  to  the  surface  of  the  liver  above  the 
gall  bladder  without  exciting  pain.  He  also 
claims  to  have  separated  the  gall  bladder 
from  the  liver  as  far  as  the  cystic  duct  with- 
out the  production  of  pain.  The  sensations 
of  pressure,  cold  and  heat  are  absent  from 
the  liver,  as  well  as  from  the  stomach  and 
„        io/«      A  intestines.     However,  tilting  of  the  liver,  or 

X IG*     1^4,      AREAS    OF 

Referred  Pain  in  pulling  on  the  common  duct,  will  cause  pain. 

Liver    Disease:  According  to   Mayo,   the   most   sensitive 

LateralView.(Ac-  .       ,      T         .     .  ... 

cording  to  Head.)      ^^^^  ^^  ^^^  liver  is  m  the  vicinity  oi   the 

common  bile  duct  about  the  neck  of  the  gall 
bladder.  This  area  receives  filaments  from  the  eleventh  and 
twelfth  dorsal,  and  the  first  lumbar  nerves.  These  nerves  also 
supply  the  diaphragm,  and  this  relationship  probably  accounts  for 
the  spasm  of  the  diaphragm  so  often  associated  with  gall-stone 
colic.  It  also  accounts  for  the  disturbance  of  diaphragmatic  action, 
even  under  deep  anesthesia,  when  in  operating  in  this  region  pres- 
sure is  made  on  this  area.  Murphy's  ^  sign  owes  its  presence  to 
this  reaction;  for  as  soon  as  the  sensitive  area  around  the  gall 
bladder  is  pressed  against  the  examiner's  fingers,  there  is  a  sudden 


*  For  a  description  of  Murphy 's  method  of  eliciting  this  tenderness,  se* 
r.Kiiti-  GalJ  Bladder  Disease. 


GENERAL    CONSIDERATIONS 


543 


restriction  of  inspiration,  and  the  characteristic  grunt  or  groan  as 
described  bv  Mnrphj  occurs. 

The  liver,  as  has  been  shown,  is  supplied  bj  both  the  sym- 
pathetic and  the  cerebrospinal  nerves.  Its  cerebrospinal  nerve 
supply  is  derived  from  the  left  vagus  through  a  communicating 
branch  which  passes  from  the  nerve  plexus  on  the  anterior  sur- 
face of  the  stomach;  thence  it  is  distributed  to  the  substance  of 


LE.FT  VAGUS 


N.  SPLANCHNIC 
MAJOR. 

N.  SPLANCHNIC 
MINOR. 
COMf^UNICATlNG 
BR.TO  LEFT  VAGUS 


-SEr^lLUNAK.    GANGLION 


COMMUNICATING    BR. 


L HEPATIC    PLEXUS 


Fig.  125. — Relationship  of  Nerve  Supply  of  Liver  to  Cerebrospinal 
AND  Sympathetic  Systems. 


the  liver  through  the  ligamentum  hepatico-duodenale  to  the  trans- 
verse fissure.  The  nerves  accompany  the  arteries  and  are  dis- 
tributed in  their  walls.  This  is  important  to  remember,  for  it 
has  a  definite  bearing  on  the  production  of  pain  in  congestive 
states  of  the  liver. 

Examination  for  Pain.  — The  grade  of  intensity  of  pain  is  of 
little  guiding  moment  in  the  diagnosis  of  diseases  of  the  liver  or 
of  its  appendages.  In  many  of  these  cases  the  patient  is  abnor- 
mally sensitive  and  is  most  irritable,  so  that  a  variety  of  subjective 
symptoms,  either  painful  or  otherwise,  are  experienced.  Under 
these  circumstances,  local  tenderness  is  most  useful  in  defining 


544  THE   LIVER,    GALL   BLADDER   AND    DUCTS 

diseases  of  these  organs.  It  may  be  elicited  by:  (1)  palpation, 
(2)  percussion,  and  (3)  sensibility  examination.  Palpation  is  of 
the  most  value  and  is  the  method  universally  employed,  the  use  of 
the  other  two  being,  as  a  rule,  confined  to  those  who  are  accustomed 
to  employ  in  their  examinations  the  refinements  of  modern  tech- 
nique. Palpation  should  be  attemf)ted  only  with  the  patient  reclin- 
ing, with  the  abdomen  flaccid,  and  the  knees  drawn  up.^ 

With  the  abdomen  relaxed  the  hand  is  placed  flat  upon  the  an- 
terior surface  with  the  finger  tips  directed  tow^ard  the  liver.  For 
this  purpose  it  is  best  to  use  the  right  hand  and  to  stand  at  the 
right  of  the  patient.  The  tips  of  the  fingers  may  now  be  pressed 
into  the  abdominal  wall  below  the  costal  arch  at  about  the  level 
of  the  ninth  or  tenth  rib,  and  the  patient  is  requested  to  take  a 
deep  inspiration.  If,  during  or  at  the  acme  of  inspiration,  pain  is 
felt,  it  is  an  indication  of  either  a  perihepatitis  or  a  gall-bladder 
disordel".  The  fingers  should  then  be  removed  to  the  area  of  the 
gall  bladder ;  the  patient  is  raised  to  a  sitting  posture  and  another 
deep  inspiration  is  taken.  Should  there  occur  a  sudden  stopping 
of  the  insj^iratory  movement,  accompanied  by  a  grunt,  gall-bladder 
disease  is  indicated.  If  nothing  special  is  noticed  on  this  proce- 
dure the  patient  is  again  directed  to  lie  flat,  and  the  right  hand  is 
placed  on  the  back  below  the  liver,  while  the  left  is  placed  above 
and  over  the  liver.  Firm  pressure  is  now  made  between  the  two 
hands  and  at  the  same  time  the  patient  is  instructed  to  breathe 
deeply.  Should  a  perihepatitis  be  present  the  patient  will  com- 
plain of  severe  pain,  which  sometimes  radiates  to  the  front  of  the 
right  shoulder.  Nodular  growths  on  the  surface  of  the  liver, 
tender  on  pressure,  may  often  be  felt  in  malignant  disease  of  the 
liver.  They  are  present  along  the  lower  margin  and  the  convex 
surface. 

Percussion  is  of  less  value  than  is  palpation  as  a  means  of 
eliciting  pain  phenomena  in  the  diagnosis  of  diseases  of  the  liver 
or  of  its  appendages.  If  the  liver  is  involved,  percussion  is  pain- 
ful over  the  entire  liver  area,  and,  to  a  slight  extent,  beyond  it. 

*  Should  the  patient  be  unable  to  relax  the  abdomen,  because,  perhaps 
of  an  associated  peritonitis,  palpation  is  of  no  value. 


PAIN    OF    THE    LIVER  545 

If  the  gall  bladder  alone  is  involved  diffuse  tenderness  extends 
around  a  much  smaller  area  of  maximum  local  tenderness  as  a 
center,  the  maximum  tenderness  corresponding  to  the  location  of 
the  gall  bladder.  The  cause  of  this  considerable  extension  of 
tenderness  is  probably  to  be  explained  by  the  range  of  vibration 
produced  by  the  percussion  stroke;  for  even  though  the  blow 
is  made  over  an  area  which  is  not  diseased  the  vibration  may  be 
communicated  to  an  adjacent  diseased  area,  and  thus  cause  pain. 

In  congestion  of  the  liver,  percussion  in  the  epigastrium  is 
productive  of  pain.  This  pain  extends  from  the  ensiform 
cartilage  to  the  lower  margin  of  the  liver. 

Sensibility  Examination. — Examination  to  light  touch,  pin- 
point and  related  sensory  tests  are  of  value  in  localizing  the 
areas  of  hyperalgesia,  which  are  identical  with  the  areas  of  re- 
flected pain,  as  elucidated  by  Head.  These  areas  are  particularly 
useful  in  defining  lesions  which  do  not  give  rise  to  any  acute  symp- 
toms, such  as  abscess  of  the  liver,  cholecystitis  not  involving  the 
peritoneum  and  cirrhosis. 

In  some  cases  of  liver,  gall-bladder  and  duct  disease  the  pain 
persists  after  the  removal  of  the  pathological  lesion  originally 
causing  it.  This  persistence,  the  so-called  habit-pain,  is,  no  doubt, 
due  to  some  pathological  change  in  the  nerve  supply  to  these 
parts,  by  which  the  excitability  to  stimuli  is  increased  to  such  an 
extent  that  reaction  to  a  painfully  excessive  degree  occurs  on  the 
slightest  irritation.  This  excitability,  which  was  originally  due 
to  the  pathological  lesion,  remains  for  some  time  as  a  habit-state 
after  the  original  cause  has  been  removed. 

PAIN  OF  THE  LIVER 

Character  of  the  Pain.  — In  disease ,  of  the  liver  the  pain,  if 
present,  is  generally  of  a  dull  nature,  while  in  involvement  of  the 
ducts  the  pain  is  of  an  intermittent,  colicky  character,  and  is  much 
more  intense  and  severe  than  it  is  in  disease  of  the  liver  proper. 

Relation  to  the  Ingestion  of  Food  and  Drink.— The  ingestion 
of  food  does  not  seem  to  have  such  an  intimate  relation  to  the 


546  THE   LIVER,    GALL   BLADDER   AND    DUCTS 

production  of  pain  in  disorders  of  the  liver  and  its  appendages 
as  it  does  in  disorders  of  the  gastrointestinal  tract  proper,  but  that 
it  is  not  entirely  without  influence  is  apparent.  In  nearly  all 
of  the  diseases  to  which  the  liver,  the  gall  bladder  or  its  ducts 
are  subject  the  movement  of  peristalsis  and  the  augmentation  of 
the  circulation,  which  the  ingestion  of  food  produces,  cause  pain. 
The  degi"ee  of  pain  from  these  factors  depends  considerably  upon 
the  extent  to  which  the  liver  structures  are  involved  and  particu- 
larly on  the  manner  of  the  involvement.  Should  a  perihepatitis 
be  present  or  adhesions  have  formed,  increased  peristalsis  and 
increase  in  the  portal  blood  pressure  in  the  liver  will  cause  more 
pain  than  if  an  abscess  or  a  cirrhosis  constitute  the  entire 
pathology;  consequently  it  is  in  the  lesions  of  most  acute  and 
recent  formation  that  the  pain  variation  is  most  influenced  by 
food  ingestion. 

The  ingestion  of  food  also  causes  pain  in  a  simple  inflamma- 
tion of  the  gall  bladder  or  of  the  ducts.  The  manner  of  the  pain 
production  may  be  explained  on  two  hypotheses : 

(1)  That  there  is  an  intimate  nervous  connection  between  the 
gall  bladder,  its  ducts,  the  stomach  and  duodenum,  so  that  when 
peristalsis  is  excited  in  the  latter  organs  there  is,  at  the  same 
time,  a  reflex  peristalsis  produced  in  the  gall  bladder  and  ducts. 
Should  the  ducts  or  gall  bladder  be  inflamed  pain  is  likely  to 
result. 

(2)  Owing  to  the  intimate  relationship  of  all  the  structures 
in  the  upper  abdomen,  an  increase  of  peristalsis  in  the  stomach 
or  the  duodenum  will,  by  pressure  or  dragging  (from  adhesions 
already  formed),  produce  pain  in  the  neighboring  inflamed  blad- 
der and  ducts.  Therefore,  if  pain  in  the  liver,  gall  bladder  or 
duct  areas  or  zones  is  present  after  the  ingestion  of  food,  inflam- 
mation or  adhesions  should  at  once  be  sought. 

Schmidt  (p.  215),  in  speaking  of  the  relationship  of  food  to 
the  production  of  pain  in  liver,  gall-bladder,  or  gall-duct  disease, 
says  that  ''the  taking  of  food  is  important  only  in  those  cases 
where  we  are  dealing  with  delicate,  anemic  individuals,  often  with 
some  degree  of  enteroj^tosis,  esiDecially  those  with  gastroptosis  and 


PAIN    OF    THE    LIVER  547 

general  atony  of  tlie  stomach."  It  does  not  seem  that  the  kind 
and  character  of  the  food,  except  when  it  is  so  indigestible  that 
it  leads  to  vomiting,  have  as  much  influence  on  the  production  of 
gall-bladder  and  duct  pains  as  does  the  quantity,  where  it  acts 
more  as  a  mechanical  agent,  producing  pain  from  its  proximal 
pressure.  In  case  the  pain  is  of  inflammatory  origin,  cold  drinks 
seem  to  ease  it. 

Relation  to  the  Movement  of  the  Body. — It  may  be  stated  as 
an  axiom  that  when,  in  disease  of  the  liver  or  its  adnexa,  pain  is 
produced  by  movement,  such  as  bending,  stooping,  and  rapid  or 
forcible  breathing,  inflammation  is  present;  while,  should  these 
movements,  including  change  of  position,  not  produce  or  increase 
the  pain,  it  may  be  accepted  as  a  fact  that  inflammation  is  absent 
and  that  any  si^ontaneous  pain  which  may  be  felt  is  due  to  stone, 
or  to  some  disease  causing  a  slow  tissue  change,  as  cirrhosis.  It 
seems  that  in  inflammatory  diseases  of  the  hollow  viscera  deliber- 
ate movements  and  change  of  position  are  not  particularly  pain- 
ful, but  that  rapid  movements,  especially  those  involving  a  jar,  are 
productive  of  great  pain.  Movements  such  as  occur  in  running, 
jumping,  riding  horseback,  traveling  in  springless  wagons,  going 
up  or  down  stairs,  and  some  movements  connected  with  respira- 
tion, such  as  sneezing,  coughing,  and  yawning,  are  very  painful. 
Positions  causing  intraabdominal  pressure  are  also  painful ;  for 
example,  the  bending  of  the  body,  stooping,  and  defecation. 

Position  of  the  Body.  —In  inflammatory  diseases  of  the  liver 
the  patient  tries,  as  much  as  possible,  to  inhibit  motion  and  to 
avoid  everything  which  causes  dragging  upon  the  liver  and  its 
attachments,  as  this  causes  pain.  To  do  this  he  generally  lies  in 
bed  upon  his  right  side.  It  might  be  urged  that  this  is  a  very  poor 
position  for  him  to  assume  in  order  to  acquire  ease,  for  in  it  the 
pressure  from  the  abdominal  viscera  is  greatest  upon  the  inflamed 
liver,  gall  bladder,  and  ducts,  and  consequently  one  would  think 
that  the  jjain  should  be  greatest.  It  is  very  true  that  in  such  a 
posture  there  is  great  pressure  on  the  liver,  etc.,  but  it  should  be 
recalled  that  the  assumption  of  the  left  lateral  posture  would  put 
considerable  traction  upon  the  ligaments,  which,  being  inflamed. 


548  THE   LIVER,    GALL   BLADDER  AND   DUCTS 

would  cause  pronouncod  })aiii.  This  pain  is  so  much  greater  than 
the  pain  produced  by  the  intraabdominal  pressure,  when  the 
patient  lies  upon  the  right  side,  that  naturally  he  assumes  the 
posture  of  relatively  greatest  ease.  In  general,  it  may  be  said  that 
more  comfort  is  obtained  in  reclining  than  in  the  upright  or  sit- 
ting posture.  This,  according  to  Schmidt,  is  due  to  the  much 
better  draining  of  the  liver  when  the  body  is  in  a  reclining  posi- 
tion. 

Likewise  in  malignant  disease  of  the  liver,  or  in  hepatic  hyper- 
trophy or  enlargement  from  any  cause,  the  patient  has  the  greatest 
ease  in  the  right  lateral  position,  for  turning  upon  the  left  side 
causes  a  great  increase  in  the  pull  and  drag  upon  the  ligaments 
by  the  enlarged  and  weighty  organ.  This  is  especially  noticeable 
in  multipara^,  because  of  the  relaxation  of  the  abdominal  wall. 
Generally,  in  these  conditions,  the  patient  likes  to  lie  upon  his 
back,  because  this  is  the  posture  of  greatest  ease.  If  nausea  and 
vomiting  also  occur  on  change  of  position,  some  additional  patho- 
logical process  in  the  stomach  or  intestine  should  be  sought. 

Relationship  to  Other  Diseases  and  Processes. — Gall-bladder 
colic  is  often  initiated  by  psychic  and  emotional  disturbances. 
It  is  also  suggested  that  it  may  be  reflexl}'  started  by  impulses 
arising  in  other  organs,  such  as  the  kidney,  genitals,  stomach,  or 
intestines.  Constipation  also  seems  to  initiate  an  attack.  Should 
pain  occur  in  the  liver  area  during  pregnancy,  or  shortly  after 
its  termination,  either  the  gall  bladder  or  the  liver  may  be 
affected.  It  seems  to  be  fairly  common  that  the  gall  bladder,  im- 
mediately after  labor,  becomes  intolerant  of  its  gall-stone  contents, 
and  tries  to  force  them  out  through  the  narrow  duct,  thus  produc- 
ing pain  and  distress,  the  so-called  gall-duct  colic.  During  preg- 
nancy, also,  the  liver  is  subject  to  metabolic  and  toxic  changes.  A 
degeneration  of  liver  tissue  leading  to  atrophy  may  result  in  the 
well-known  yellow  atrophy.  While  the  pathologic  changes  asso- 
ciated with  this  disease  are,  as  a  rule,  painless,  yet  in  many  cases, 
because  of  parenchymatous  or  peripheral  inflammation,  pain  may 
be  a  prominent  symptom. 

Typhoid  fever,  at  times,  in  its  early  stages  produces  symp- 


PAIN    Oi'    THE    LIVER  '  549 

toms  resembling-  cholecystitis,  and,  in  some  instances,  gall-bladder 
inflammation  very  likely  is  present.  When  symptoms  of  cholecys- 
titis do  occur  in  typhoid  fever  they  last  only  for  a  few  days,  and 
then  become  merged  into  those  typical  of  the  fever.  During  con- 
valescence pain  and  tenderness  over  the  gall-bladder  area  may 
also  occur,  and  in  these  circumstances  they  indicate  gall-bladder 
infection.  Should  the  inflammation  become  so  severe  as  to  re- 
quire operation,  the  gall  bladder  is  found  to  be  inflamed,  and  in 
many  cases  filled  with  pus. 

Liver  disorders  occurring  during  the  course  of  dysentery,  par- 
ticularly that  due  to  amoeba  coli,  should  at  once  cause  a  search  to 
be  made  for  liver  abscess.  Enteroptosis  may  be  associated  with 
gall-duct  disease,  and  the  pull  and  drag  upon  the  liver  and  its 
appendages,  produced  by  jarring,  running,  or  jumping,  may, 
especially  if  a  movable  right  kidney  is  present,  incite  a  gall-duct 
colic  in  one  who  is  subject  to  such  attacks. 

Time  of  Appearance  of  Pain. — Liver  and  appendage  pain  i& 
generally  incited  or  at  least  made  worse  by  the  onset  of  digestion, 
particularly  after  the  food  passes  through  the  pylorus  and  enters 
the  small  intestine.  This,  as  a  rule,  occurs  from  two  to  four 
hours  after  eating. 

Gall-stone  pain  generally  occurs  in  paroxysms.  The  pain 
paroxysms  may  be  incited  by  vomiting  and  by  excesbive  motion.^ 
Should  a  colic  resembling  gall-stone  colic  appear  in  a  person  of 
advanced  age,  it  is  more  likely  that  the  condition  is  one  of  carci- 
noma of  the  gall-bladder  than  a  cholelithiasis.  Gall-stone  colic, 
like  all  other  colics,  seemingly  has  a  tendency  to  occur  most  fre- 
quently at  night.  This  possibly  is  only  a  supposition  (see  Diurnal 
Variation  of  Pain).  If  the  pain  is  due  to  a  hepatitis  it  may  last 
for  a  long  time,  the  constant  pain  being  interrupted  by  exacerba- 
tions, which  indicate  the  flaring  up  of  a  dormant  infection.  In 
gall-stone  colic,  on  the  other  hand,  the  pain  is  not  so  continuous, 

^  Gall  stones  may  lie  latent  in  a  gall  bladder  for  years  until,  suddenly, 
the  patient  has  an  attack  of  indigestion  and  the  latent  disturbance  at  once 
becomes  active.  The  violent  retching  and  vomiting  which  accompany  the  indi- 
gestion have  dislodged  the  calculi  from  their  resting  place  in  the  bladder  and 
one  or  more  are  forced  into  the  cystic  duct,  thus  causing  the  pain. 


550  THE  LIVER,   GALL   BLADDER   AND   DUCTS 

but  occurs  in  paroxysms,  which  disappear  on  the  passage  of  the 
stone  or  on  its  retrogression  into  the  gall  bladder.  In  these  cases 
there  is  generally  a  history  of  a  previous  attack,  with  a  similar 
pain,  accompanied  by  vomiting,  jaundice,  light-colored  stools,  bile 
in  the  urine,  and  constipation.  A  history  of  gastric  disturbances, 
associated  with  pain  in  the  right  hypochondrium,  should,  in  all 
cases,  lead  to  the  suspicion  of  gall  stones  as  the  cause  of  the  dis- 
order. 

Neuralgia. — Sometimes  the  nerves  supplying  the  liver,  it  is 
said,  are  subject  to  what  is  called  neuralgia.  Allbut  describes 
such  a  state  of  the  liver,  but  Maylard  doubts  its  existence.  The 
latter  observer  quotes  a  case,  but  the  signs  and  symptoms  which 
he  noted  seem  to  be  rather  those  of  a  hepatitis  than  of  a  neuralgia. 
The  case  quoted  by  Maylard  from  Allbut  is  as  follows: 

"Mr.  W.  A.  ,  aged  32,  whose  habits  are  temperate, 

whose  health  is  exceptionally  good,  and  who  presents  no  obvious 
disorder  of  function,  has  called  upon  me  at  intervals  for  three 
years.  Four  months  before  his  first  visit  he  was  taken  with  a 
pain  which  he  refers  precisely  to  the  seat  and  extent  of  the  liver. 
This  pain  has  often  recurred,  and  observes  no  period  of  recurrence, 
except  that  it'  always  attacks  him  at  night.  It  is  a  'miserable 
pain.'  He  arises  and  paces  the  floor  for  hours.  He  maps  out  the 
liver,  of  whose  seat  he  was  previously  ignorant,  with  curious  ex- 
actness. He  has  had  no  jaundice,  nor  does  he  suffer  from  consti- 
pation. The  i:)ain  does  not  stab  nor  radiate  as  spinal  pains  do. 
On  bromid  and  arsenic  he  recovered  and  was  well  for  twelve 
months,  when  worry  and  overwork  recalled  the  attacks.  The 
family  history  j)oints  to  rheumatism." 

Pains  Due  to  the  Disturbance  of  the  Liver  Substance 
Proper.  — The  pains  due  to  disturbance  in  the  liver  proper  are 
either  extra-  or  intraparenchymatous  in  origin. 

(1)  Extraparenchymatous  pains  are  caused  by  (a)  distention 
of  the  capsule;  (b)  inflammation  of  the  capsule  by  inflammatory 
products,  etc. ;    (c)   traction  from  adhesions  joining  the  capsule 


PAIN    OF    THE   LIVER  551 

to  adjacent  organs,  or  to  the  parietal  peritoneum;  (d)  traction  by 
the  liver  on  adjacent  organs  through  its  ligaments,  because  of  dis- 
placement. 

(2)  Intraparenchymatous  pains  are  produced  by  irritation 
of  the  nerves  in  the  liver  substances  by  inflammatory  products, 
tumors,  etc.  The  stimulus  is  carried  by  means  of  the  sympathetic 
fibers,  whence,  depending  mostly  upon  the  strength  of  the  stimu- 
lus, it  is  generally  reflected  to  the  body  wall  and  is  there  per- 
ceived as  pain. 

Intrapakenchymatous  Paix. — Distention  of  the  live)'  causes 
pain,  especially  when  the  enlargement  is  acute.  Chronic  disorders 
of  the  liver  causing  an  increase  of  the  parenchyma  (of  substance 
mass)  are,  as  a  rule,  not  painful.^ 

The  principal  causes  of  acute  distention  of  the  liver  are 
passive  and  active  congestion.  Passive  congestion  is  due  to  a 
backward  stasis,  either  in  the  blood  circulatory  system  (hepatic 
or  portal  vein),  or  in  the  bile  circulatory  system,  such  as  is  pro- 
duced by  closure  of  the  lumen  of  the  bile  ducts  from  inflammatory 
swelling  or  gall  stones.  Acute  distention,  the  result  of  active 
congestion  of  the  liver  with  involvement  of  the  parenchymatous 
nerves,  occurs  in  abscesses  (toxic  or  pyemic),  in  rapid-growing 
cancer  and  sarcoma,  and  in  acute  generalized  inflammation  of 
the  liver  substance.  In  these  conditions  there  is  present  an  inter- 
stitial hepatitis,  and  this  adds  considerably  to  the  pain  content  by 
irritating  the  local  nerves.  Acute  distention  of  the  liver  may  also 
be  caused  by  active  hyperemia  of  the  liver,  the  result  of  over- 
eating. 

Patients  subject  to  a  hepatic  congestion,  due  to  a  stasis,  gen- 
erally complain  of  a  sense  of  pressure  in  the  liver  region.  Pain, 
if  present,  is  more  of  a  dull  ache  around  the  costal  arch  of  the 
right  side.  Referred  pains  are  not  common  in  this  class  of  dis- 
orders. The  pain  is  made  worse  by  any  exertion  of  the  patient, 
such  as  going  up  stairs,  running,  and  walking,  while  it  markedly 

'  It  is  claimed  by  Schmidt  that  distention  of  the  liver  capsule  is  a  cause 
of  pain  production  in  malaria,  pernicious  anemia,  paroxysmal  hemoglobinuria, 
leukemia,  and  diabetes. 


552  THE   LIVER,    GALL   BLADDER   AND    DUCTS 

decreases  when  the  patient,  and  consequently  the  heart,  is  in  a 
state  of  rest.  The  pain  is  also  worse  when  the  patient  is  in  an 
upright  position,  and  is  increased  by  deep  breathing,  by  the  inges- 
tion of  certain  kinds  of  food,  such  as  albumins,  and  by  the  drink- 
ing of  alcoholic  liquors.  It  is  also  made  worse  by  a  sudden  change 
of  position  and  by  lying  on  the  right  side. 

According  to  Murchison  there  are  ^^resent  in  congestion  of  the 
liver:  (1)  a  feeling  of  tightness  in  the  liver  region;  (2)  more  or 
less  tenderness,  rarely  acute  on  pressure  below  the  margins  of  the 
ribs  on  the  right  side;  (3)  a  pain  which  may  extend  up  to  the 
right  shoulder  and  which  is  increased  after  meals.  According  to 
the  same  author,  lying  on  the  left  side  produces  a  feeling  of  drag- 
ging or  weight  in  the  hepatic  region.  Pressure  on  or  percussion 
over  the  liver  area  is  painful.  According  to  Schmidt  the  maximum 
pain  is  felt  in  percussion  along  the  linea  alba  and  extends  in  this 
line  from  the  tip  of  the  ensiform  down  to  the  liver  margin.  He 
also  claims  that  the  tenderness  to  percussion,  in  a  case  of  back- 
ward congestion  from  a  non-compensating  heart,  will,  when  under 
treatment  with  digitalis,  become  less  as  improvement  occurs. 

Another  differential  point  is  that  the  pain  of  congestion,  un- 
like that  of  hepatitis,  is  rarely  referred  to  the  right  shoulder  or 
scapula.  When  acute  congestion  occurs  the  liver  becomes  larger 
and  harder.  The  patient  may  be  aware  of  this  change,  the  exact 
nature  of  wliich  he  does  not  understand,  for  he  often  complains 
of  the  increasing  hardness  of  the  abdomen. 

In  passive  congestion  of  the  liver,  pain  and  tenderness  are  not 
prominent  factors,  unless  the  congestion  is  sudden  in  its  onset,  for 
the  passive  congestions  of  slow  onset  gradually  distend  the  cap- 
sule, which,  without  pain,  accommodates  itself  to  the  increase  in 
the  intracapsular  bulk,  A  pathognomonic  sign  of  backward 
(stasis)  congestion  is  expansile  pulsation  of  the  liver,  systolic  in 
time. 

A  liver  which  already  is  afflicted  with  cirrhosis  cannot  become 
congested.  Therefore,  if  passive  congestion  is  general  and  it  does 
not  appear  in  the  liver  a  diagnosis  of  cirrhotic  liver  may  be  made. 
Should  perihepatitis  ensue  during  passive  congestion  of  the  liver 


PAIN    OF    THE   LIVER  553 

the  pain  of  the  congestion  is  aggi'avated  by  the  much  more  acute 
and  severe  pain  of  the  perihepatitis  (q.  v.). 

Besides  the  congestion  due  to  the  backward  stasis  of  blood, 
a,  biliary  stasis  may  also  occur,  but  this  is  not  of  such  a  type  that 
pain  is  common.  The  pressure  from  the  retained  bile  generally  is 
not  sufficient  to  distend  the  liver  capsule  and  cause  pain.  It  acts 
especially  as  a  j^redisposing  cause  for  pain  production,  for  the 
biliary  stagnation  produces  a  condition  favorable  to  inflammatory 
reaction,  which  may  ensue  and  turn  the  passive  congestion  into 
an  active  inflammation. 

Congestion  due  to  acute  inflammatory  lesions  causes  both  a 
distention  of  and  an  irritation  of  the  capsule.  This  irritation 
may  be  productive  of  a  very  mild  or  a  very  severe  inflammation, 
which  in  turn  may  result  in  the  formation  of  adhesions.  There  is 
also  a  great  tendency  for  infectious  inflammatory  diseases  of  the 
liver  to  form  abscesses.  The  abscesses  are  of  two  types:  (a) 
pyemic  and  (b)  tropical.  The  pyemic  abscesses  are  generally 
small  and  multiple  and  are  painful  only  because  of  the  secondary 
changes  which  they  induce. 

Some  of  the  abscesses  are  near  the  peritoneal  surface,  and  as 
a  consequence  they  involve  this  membrane.  Adhesions  quickly 
form,  and  much  of  the  pain  is  due  to  the  traction  exerted  upon 
them  by  the  liver.  A  description  of  the  pain  due  to  a  single  abscess 
and  its  complications  is  given  by  Hotchkiss,  Kew  York  Surgical 
Society,  March  10,  1909.     He  says: 

"The  onset  of  the  condition  Degan  as  a  pain  in  the  epigas- 
trium, which  lasted  for  two  days  without  relief;  but  after  this 
it  was  less  severe  and  lasted  for  two  years,  being  modified  by  the 
kind  of  food  which  the  patient  ate.  It  came  on  in  the  morning 
when  he  woke  up,  was  confined  to  the  epigastrium,  did  not  radiate, 
and  was  often  relieved  by  a  cup  of  hot  fluid,  such  as  tea.  The 
pain  always  returned  after  the  other  meals,  but  was  not  as  severe, 
and  generally  was  relieved  by  pressure  and  hot  drinks.  It  was 
worse  when  lying  on  the  side ;  also,  after  the  taking  of  solid  food 
and  after  exercise.  On  physical  examination  there  was  an  area 
of  tenderness  and  muscular  spasm  over  the  upper  segment  of  the 


554  THE   LIVER,    GALL   BLADDER   AND   DUCTS 

right  rectus  muscle.     An  abscess  was  found  in  the  central  part  of 
the  liver,  adhesions  to  the  diaphragm  being  present." 

The  pain  in  these  conditions  in  which  the  liver  is  bound  to  the 
diaphragm  or  to  the  abdominal  wall  by  adhesions  is  increased  by 
coughing,  sneezing,  and  deep  breathing.  The  respirations,  because 
of  the  pain,  are  generally  short  and  rapid.  Tenderness  over  the 
abscess  area  is,  as  a  rule,  present. 

Tropical  abscess  is  generally  free  from  pain;  because,  in  the 
first  place,  it  is  of  slow  development  and  is  in  the  interior  of  the 
liver;  and,  secondly,  because  it  is  free  from  inflammatory  re- 
action. Should  it  progress  toward  the  surface  and  the  peritoneum 
become  involved,  pain  is  produced.  If  it  is  on  the  convex  surface 
and  involves  the  diaphragm  pain  over  the  right  shoulder  is  also  a 
prominent  symptom. 

In  cirrhosis  of  the  liver  the  pain,  if  present,  is  due  chiefly  to 
an  associated  neuritis,  which  may  be  caused  either  by  previous 
alcoholism  or  by  the  toxemia  which  is  associated  with  this  disease. 
This  neuritis  is  confined  principally  to  the  arms  and  the  legs. 

In  biliary  cirrhosis  there  is  generally  a  sense  of  weight  in  the 
right  hypochondrium ;  and  periodic  attacks  of  pain  with  tender- 
ness over  the  liver  and  spleen  occur. 

New  Growths. — In  new  growths  of  the  liver  pain  production 
seems  to  depend  upon  two  factors:  (1)  the  location  of  the  growth 
in  reference  to  the  capsule  of  the  liver,  and  (2)  the  rapidity  of 
the  growth. 

Growths  which  involve  the  capsule  are  generally  more  painful 
than  those  which  occur  in  the  substance  of  the  gland.  When  the 
growth  is  superficial  a  certain  amount  of  perihepatitis  is  to  be  ex- 
pected, and  this  not  only  causes  pain  directly,  but  also  indirectly, 
by  the  adhesions  which  are  produced.  According  to  Rolleston  the 
pain  due  to  malignant  disease  may  be  almost  constant  in  the 
right  hypochondrium,  but  often  is  especially  marked  in  the  back, 
in  the  shoulder,  or  in  the  loin.  It  often  occurs  in  paroxysms, 
frequently  radiates  to  the  right  shoulder,  and  is  worse  at  night 
(characteristic).  Early  in  the  disease  there  is  only  a  sense  of 
discomfort  or  dragging,  pain  being  a  later  result  of  the  process. 


PAIN    OF    THE   LIVER  555 

Should  the  gi'owths  occur  arouud  the  common  duct  symptoms  re- 
sembling gall-stone  colic  are  produced.  Tenderness  is  well 
marked  in  growths  of  rapid  development.  This  tenderness  is  fre- 
quently a  sign  of  the  associated  perihepatic  inflammation. 

Cysts,  especially  hydatid,  in  the  liver  and  its  appendages  are 
causes  of  pain.  The  pain  in  these  conditions  is  not  marked,  unless 
the  growth  is  rapid  or  the  peritoneum  is  involved.  In  the 
first  instance  the  pain  is  dull  and  aching  and  is  due  to  distention 
of  the  liver  capsule.  In  the  second  it  is  the  result  of  peritonitis, 
is  sharper  and  more  acute,  and  is  definitely  localized  to  the  upper 
abdomen.  In  cystic  formation  the  abdomen  over  the  margin  of 
the  liver  -is  tender  and  often  the  irregular  nodosities  of  the  cystic 
gi*OT\i;hs  can  be  felt.  Sometimes  the  passage  of  small  cysts  through 
the  cystic  and  common  duct  produces  a  typical  gall-duct  colic 
(Schmidt).  These  attacks,  like  those  of  calculi  colic,  are  most 
common  during  the  night,  and  the  pain  is  worse  in  the  left 
lateral  posture.  The  onset  of  hiccoughs  indicates  diaphragmatic 
involvement.  Syncope  is  common.  The  presence  of  booklets  in 
the  fluid  removed  by  exploratory  puncture  is  confirmative  of  the 
condition.  Tenderness  is  generally  a  sign  of  suppuration.  When 
this  occurs  there  are  a  rapid  pulse  and  an  elevation  of  temperature. 
In  some  cases,  owing  to  pressure  on  the  stomach  and  intestines, 
symptoms  of  obstruction  of  either  one  or  of  both  of  these  two 
organs  may  supervene.  The  rapidity  of  the  growth  influences  to 
a  great  extent  the  intensity  of  the  resulting  pain. 

Growths  of  slow  development  generally  are  painless,  because 
with  the  slow  increase  in  size  the  adjacent  liver  cells,  having  had 
an  opportunity  to  adjust  themselves  to  changed  surroundings,  give 
rise  to  no  physical  or  economic  disturbances.  In  growths  of  rapid 
development,  however,  this  does  not  occur,  nor  has  the  capsule 
had  an  opportunity  to  adjust  itself  to  excess  of  pressure,  and 
so  pain  is  produced. 

Secondary  (metastatic)  gro\\i:hs  in  the  pleura  and  the  perito- 
neum also  cause  considerable  disturbance.  The  pain  and  local  ten- 
derness, the  results  of  these  conditions,  generally  follow,  by  a 
iiotic^able  interval,  the  pains  and  tenderness  due  to  the  primary 


556  THE   LIVER,    GALL   BLADDER   AND    DUCTS 

growth.  Sometimes  the  common  or  cystic  duct  may  be  partially 
occluded  by  the  growth.  Then  biliary  colic  is  added  to  the  symp- 
toms already  present.  In  some  cases  gall  stones  are  present  as  a 
complication,  and  these  add  their  own  particular  syndrome  to  the 
symptom-complex. 

Rapid  progress  of  the  disease  is  an  indication  that  the  growth 
is  probably  of  a  primary  nature.  This  belief  is  strengthened  if 
the  pain  first  complained  of  was  in  the  liver  region.  Should  the 
cancer  be  primary  death  generally  occurs  in  three  or  four  months. 
Even  in  growths  involving  the  liver  secondarily,  death  generally 
occurs  Avithin  six  months  of  the  involvement. 

Malignant  disease  of  the  liver,  which,  as  a  rule,  is  painful,  is 
fre'^r^ntly  confused  with  cirrhosis,  which  is  painless.  Other 
diagnostic  points  are:  that  in  cirrhosis  the  spleen  and  liver 
are  both  enlarged ;  also  in  cirrhosis  the  liver  enlargement  is  more 
uniform  than  in  malignant  disease  and  cachexia  is  less  marked. 
If  in  malignant  disease  of  the  liver  pain  should  be  felt  in  the  epi- 
gastrium and  vary  with  the  ingestion  of  food,  a  secondary  in- 
volvement of  the  stomach  is  very  likely  present.  Growths  in  the 
liver,  secondary  to  cancer  of  the  stomach,  or  of  the  intestine,  are 
generally  more  painful  than  secondary  growths  in  other  locations, 
because  the  accompanying  inflammation  is  much  greater. 

In  the  secondary  involvement  of  the  liver  the  pain  follows 
that  caused  by  the  primary  growth,  wherever  that  may  have  been. 
Should  the  primary  growth  have  been  in  the  stomach  the  primary 
pain  would  indicate  stomach  involvement ;  and  this,  in  case  of 
liver  metastasis,  would  be  followed  in  an  appreciable  interval  by 
pain  in  the  region  of  the  liver  or  gall-bladder. 

Syphilis  of  the  liver  is  indicated  by  attacks  of  pain,  rapid  in- 
crease in  size  of  the  liver,  and  by  fever.  Tlie  enlarged  liver  is 
tender,  and  has  an  uneven  surface.  The  left  lobe  is  more  fre- 
quently affected  than  the  right,  therefore  the  left-sided  localiza- 
tion of  the  pain  under  the  left  hypochondrium.  There  is  also  a 
certain  amount  of  inflammatory  reaction  accompanying  all  syphi- 
litic growths,  and  this  in  turn  causes  inflammation  of  the  cover- 
ing of  the  liver  (perihepatitis)   and  of  the  adjacent  peritoneum. 


PAIN    OF    THE    LIVER  557 

In  view  of  these  facts,  it  is  hardly  necessary  to  add  that  in  all 
cases  of  pain  in  the  liver  area,  with  enlargement  of  the  liver, 
syphilis  should  at  least  be  considered  and  the  Wassermann  reac- 
tion determined. 

ExTRAPARENCHYMATOus  Pain. — PeriJicpatitis.  —  Intimately 
associated  with  the  foregoing  disorders,  and  generally  following 
as  the  result  of  one  or  the  other  of  them,  is  inflammation  of  the 
capsule  of  the  liver,  the  so-called  perihepatitis.  Of  these,  there 
are  two  varieties,  the  acute  and  the  chronic.  The  acute  variety 
as  a  primary  condition  is  never  met  with  in  the  temperate  zone, 
It  has  been  found  as  a  primary  disorder  in  the  tropics,  because 
the  congested  state  of  the  liver  in  inhabitants  of  these  regions 
easily  lends  itself  to  an  inflammatory  process.  The  inflammation 
originates  from  local  extension  of  a  diseased  process,  either  from 
within  the  liver  substance  (acute  hepatitis,  abscess,  new  growths) 
or  from  some  adjacent  viscera.  In  both  the  acute  and  chronic 
form  of  j)erihepatitis  a  friction  rub  is  generally  heard  over  the 
liver  region  on  auscultation.  It  may  also  be  felt  on  palpation 
over  the  same  area. 

The  extrahepatic  disorders  from  which  perihepatitis  may  re- 
sult are :  peritonitis  in  the  lesser  or  greater  peritoneal  sac ;  rup- 
ture of  viscera  adjacent  to  the  liver,  as  the  gall  bladder,  stomach, 
or  duodenum;  and  inflammation  of  adjacent  viscera.  Here  the 
inflammation  is  communicated  to  the  peritoneum,  or  to  the  con- 
necting ligaments,  and  thus  is  transferred  to  the  liver  capsule 
(Roberts).  In  any  of  these  conditions  the  character  of  the  pain 
present  previous  to  the  perihepatitis  may  give  some  idea  of  the 
primary  source  of  involvement. 

In  some  intrahepatic  lesions  pain  is  not  present,  although,  as 
a  rule,  some  discomfort  is  experienced. 

Acute  Hepatitis. — The  pain  in  acute  hepatitis  is  quite  sudden 
in  its  onset,  while  that  of  the  chronic  variety  is  of  a  more  gradual 
develoj)ment.  In  either  case  the  pain  is  directly  over  the  liver 
and  is  made  worse  by  such  motions  as  occur  in  respiration,  in 
changing  the  position  of  the  body,  or  in  contraction  of  the  abdomi- 
nal muscles.     The  liver  is  also  tender  to  the  touch.     A  method  of 


558  THE    LIVER,    GALL   BLADDER   AND    DUCTS 

palpation  suitable  to  define  this  condition  is  to  place  one  hand  on 
the  hypochondrium  over  the  liver  and  the  other  on  the  back  under- 
neath the  liver.  Kow  make  a  to-and-fro  motion  with  the  two 
hands,  when,  if  hepatitis  is  present,  pain  will  result.  Besides  this 
local  pain  there  is  also  present  a  referred  pain,  felt  in  the  right 
shoulder,  in  the  area  between  the  clavicle  and  the  acromion  process 
of  the  scapula  on  the  front  of  the  chest  (Cantli). 

Displacement  of  the  Liver. — A  further  cause  of  hepatic  pain 
is  traction  on  adjacent  organs  by  an  enlarged  liver  through  its 
ligaments.  These  ligaments  are  five  in  number:  the  falciform  or 
suspensory  ligament,  the  round  ligament,  the  two  lateral  liga- 
ments, and  the  ligamentum  venosum.  Any  or  all  of  these  may 
be  stretched  or  pulled  upon  in  liver  displacement. 

In  liver  displacement  (hepatoptosis)  the  liver  may  be  rotated 
in  one  of  two  directions:  around  the  transverse  axis,  so  that  its 
upper,  convex  surface  becomes  anterior ;  or  around  the  vertical 
axis,  either  to  the  left  or  to  the  right.  The  latter  is  the  more 
common.  In  this  the  right  lobe  becomes  inferior,  and  the 
inferior  surface  is  turned  to  the  left.  In  a  left-sided  rotation  the 
left  lobe  becomes  the  lower,  and  the  inferior  surface  is  turned 
to  the  right.  Rotation  to  the  left  will  produce  more  traction  on 
the  ligaments  connected  with  the  left  lobe  of  the  liver,  while  rota- 
tion to  the  right  Avill  cause  traction  to  be  exerted  on  the  ligaments 
connected  with  the  right  lobe.  In  either  case  the  pull  is  chiefly 
upon  the  diaphragm  and  has  about  the  same  degree  of  force,  irre- 
spective of  the  direction  of  the  turning.  The  traction  due  to  rota- 
tion will  produce  the  same  diaphragmatic  symptoms  as  a  down- 
ward displacement  of  the  liver  (q.  v.). 

Downward  displacement  of  the  liver  will  produce:  (1)  a 
pull  on  the  diaphragm;  (2)  a  pull  on  the  left  vena  cava;  (3)  a 
rotation  and  angulation  of  the  portal  vein,  hepatic  artery,  and 
common  duct;  (4)  a  slight  rotation  of  the  upper  pole  of  the  right 
kidney;  and   (5)   a  compression  of  organs  below  the  liver. 

The  pull  on  the  diaphragm  which  is  exerted  through  the  falci- 
form ligament,  which  is  almost  in  the  center  of  the  diaphragm, 
?ind  through  the  coronary  and  triangular  ligaments^  which  are  to 


PAIN    OF    THE   LIVER  559 

the  right  of  the  median  line,  will  produce  traction  on  the  right  half 
of  the  diaphragm,  and  thence  through  the  diaphragmatic  attach- 
ment, on  the  right  ribs.  This  is  felt  as  a  dragging  sensation,  or 
discomfort,  in  the  right  lower  chest  at  the  points  of  insertion  of 
the  diaphragm  on  the  six  lower  ribs. 

Because  of  the  pull  on  the  vena  cava,  traction  is  propagated 
up  into  the  chest  underneath  the  sternum,  even  as  far  as  the  base 
of  the  heart.  Here  the  inferior  cava,  because  of  its  intimate  asso- 
ciation with  other  structure,  is  firmly  fixed,  and,  as  a  consequence, 
it  is  at  this  point  that  the  greatest  traction  is  made  and  the  pain, 
which  is  referred  to  the  anterior  chest  wall,  is  produced.  In  other 
cases  the  pain  is  propagated  further,  being  transmitted  through  the 
cervical  fascia  and  is  felt  as  high  as  the  base  of  the  neck. 

Owing  to  the  rotation  of  the  liver,  a  twist  or  angulation  of 
the  portal  vein,  hepatic  artery,  or  the  common  or  cystic  bile  duct 
may  occur.  A  twist  and  partial  occlusion  of  the  portal  vein  or 
hepatic  artery  may  not,  of  necessity,  be  provocative  of  pain, 
though  an  occlusion  of  any  of  the  bile  ducts,  provided  it  is  acute, 
is  almost  sure  to  be.  When  an  occlusion  of  the  ducts  occurs,  the 
pain  may  be  due  directly  to  the  occlusion,  or  the  occlusion  may 
lead  indirectly  to  pain  production  from  the  tendency,  when  stag- 
nation of  bile  takes  place,  to  the  formation  of  gall  stones. 

The  rotation  of  the  kidney  may  cause  the  renal  colic  some- 
times present  in  hepatic  displacement.  The  liver,  when  it  is  dis- 
placed, causes,  through  its  ligamentous  attachments  to  the  upper 
pole  of  the  right  kidney,  a  downward  and  inward  rotation  of  the 
upper  pole  of  the  kidney,  with  a  tendency  to,  and  sometimes  an 
actual,  kinking  of  the  ureter.    This  is  the  cause  of  the  pain. 

All  the  pains  due  to  hepatoptosis  are  relieved  when  the  patient 
assumes  the  reclining  posture  and  are  increased  in  the  upright 
position.  When  the  pain  is  not  relieved  by  lying  down  it  can  be 
assumed  that  some  permanent  pathological  change  has  taken  place 
in  adjacent  organs,  such  as  cholecystitis  in  the  gall  bladder,  colitis 
in  the  colon,  and  chronic  intestinal  disturbance  in  the  small 
bowel,  or  that,  in  the  reclining  posture,  either  traction  or  pressure 
is  exerted  on  them  by  the  enlarged  liver. 


560  THE   LIVER,    GALL   BLADDER   AND   DUCTS 

Brown  (Osier's  "System")  describes  tlie  pain  of  liepatoptosis 
either  as  spontaneous,  or  as  being  brought  on  by  jumping,  walk- 
ing, raising  the  right  arm,  sneezing,  coughing,  and  yawning,  while 
sometimes  paroxysms  of  pain  occur  without  apparent  cause.  The 
pain  is  usually  relieved  by  having  the  patient  lie  on  the  back  or 
on  the  right  side,  or  by  manual  replacement  of  the  organ.  The 
pain  is  commonest  in  the  right  hypochondriac  and  epigastric 
regions,  radiating  thence  toward  the  right  shoulder  or  to  the  flank. 
Pressure,  though  rarely  painful,  often  produces  peculiar  sensa- 
tions in  various  portions  of  the  body,  especially  in  the  right  arm 
and  shoulder. 

Adhesions. — Following  perihepatitis,  and  a  result  of  it,  adhe- 
sions take  place  between  the  liver  and  the  adjacent  structures. 
Adhesions  between  the  liver  and  its  associated  structures,  gall 
bladder  and  bile  ducts,  may  be  present  without  the  production  of 
pain,  though  pain  is  likely  to  occur  when  the  patient  changes  his 
position,  or  during  some  phase  of  digestion.  Should  the  pain  be- 
come prominent  on  change  of  position,  the  area  in  which  it  is  felt 
is  a  good  indication  of  the  location  of  the  adhesions,  provided  they 
lie  between  the  liver  and  the  parietal  peritoneum.  Should  ad- 
hesions not  be  present  in  this  location,  but  between  the  liver  and 
some  intraabdominal  organs,  the  pain,  or  rather  discomfort,  will 
be  referred  to  the  area  to  which  this  organ  refers  its  disc6mfort 
and  distress.  Should  adhesions,  for  instance,  be  present  between 
the  liver  and  the  stomach  or  intestine,  the  reference  will  be  to  the 
somatic  area  associated  with  the  stomach  and  intestine,  and  not 
to  the  area  associated  with  the  liver.  In  cases  in  which  dense  ad- 
hesions exist  between  the  stomach  and  the  gall  bladder  the  pain 
may  be  in  the  epigastrium  or  over  the  ensiform  cartilage.  It  is 
somewhat  acute  and  is  more  or  less  severe,  especially  on  movement. 
Should  the  pain  be  especially  prominent  at  the  time  of  gastric 
digestion  it  is  reasonable  to  assume  that  the  adhesions  involve  the 
stomach.  Should  it  occur  at  the  time  of  the  colonic  passage  of 
food  it  is  most  probable  that  the  colon  is  the  adhering  organ.  In 
all  cases  of  adhesive  formations  there  is  a  history  of  previous 
acute  pain,  the  result  of  infection  of  the  liver,  gall  bladder,  ducts. 


PAIN    OF    THE   LIVER  561 

or  adjacent  viscera,  with  a  gi'adually  developing  chronic  (ad- 
hesive) pain. 

Universal  chronic  serositis,  a  disease  in  which  all  the  serous 
membranes  are  involved,  is  generally  free  from  hepatic  pain  and 
is  slow  in  its  development.     Its  principal  symptom  is  ascites. 

Essential  Diseases  of  the  Liver. — Pain  is  absent  in  amy- 
loid enlargement,  fatty  liver,  leukemic  enlargement,  adenoma, 
cysts  (simple),  angioma  and  fibroma.  Pain  is  present  in  the 
cirrhoses,  hepatitis,  acute  yellow  atrophy,  syphilis  and  new 
gi'owths,  hydatid,  etc. 

In  chronic  atrophic  cirrhosis  the  pain  is  dull  and  heavy  in 
the  first  stage.  There  is  also  present  tenderness  due  to  intermit- 
tent attacks  of  perihepatitis.  In  hepatitis  the  pain  is  over  the 
liver  and  is  propagated  to  the  area  between  the  clavicle  and  the 
acromion  process  of  the  scapula  on  the  front  of  the  chest.  The 
liver  is  very  tender  on  pressure.  In  portal  cirrhosis  pain  is  absent 
in  the  last  stages.  In  the  early  stages  there  is  a  dull,  heavy  pain. 
Tenderness  in  the  right  side  (hypochondrium),  intermittent  in 
character,  is  also  present.  In  biliary  cirrhosis  there  are  periodic 
attacks  of  pain  with  fever  and  jaundice.  Tenderness  is  found  over 
the  liver  and  spleen. 

In  acute  yellow  atrophy  pain  is  nearly  always  present  and  is 
often  spontaneous.  Tenderness  is  so  marked  that  it  can  be  elicited 
when  the  patient  is  unconscious.  In  syphilis  there  is  no  pain, 
unless  the  gi'owth  is  tertiary  and  a  perihepatitis  has  resulted  with 
inflammation  of  the  capsule  ;  in  this  condition  |)ain  is  common.  In 
lymphadenoma  pain  is  absent.  In  hydatid  cystic  disease  the  only 
discomfort  may  be  a  feeling  of  weight  or  of  dragging  in  the  abdo- 
men. If  the  peritoneal  covering  of  the  liver  is  inflamed  pain  is 
present  on  respiration.  Tenderness  is  also  a  marked  symptom. 
In  fatty  liver  there  is  no  pain.  The  enlargement  is  slow  and  the 
liver  surface  is  smooth.  Lardaceous  disease  is  generally  secondary 
to  other  conditions.  The  enlargement  is  constant,  slow,  and  pain- 
less. Simple  cysts  of  liver  are  rarely  large  enough  to  cause  any 
special  disturbance.  In  adenoma,  angioma,  myxoma,  fibroma, 
and  lipoma  there  is  no  pain. 


562  THE   LIVER,    GALL   BLADDER   AND    DUCTS 


GALL  BLADDER 

General  Etiology. — The  pain  of  gall-bladder  disease  is  due  to 
over-distention  of  the  walls,  excessive  contraction  of  its  muscular 
coat,  or  irritation  of  the  mural  nerves  from  either  of  the  above,  or 
from  inflammatory  processes,  which  may  be  intra-  or  extramural. 
Intramural  inflammation  aifects  only  the  mucosa  and  musculature, 
while  extramural  inflammation  affects  the  peritoneum.  The  drag- 
ging by  adhesions  also  produces  pain. 

Over-distention  of  the  gall  bladder  is  the  cause  of  pain  in 
such  disorders  as  hydrops  of  the  gall  bladder,  but  only  when  the 
condition  is  acute.  It  is  most  likely  that  over-distention  of  the 
gall  bladder  does  not  of  itself  cause  pain,  unless  there  is  an 
obstruction  to  the  onward  flow  of  bile,  such  as  may  be  produced 
by  either  a  stone  in  or  an  inflammation  of  the  cystic  or  common 
duct.  The  obstruction  hinders  the  flow  of  the  bile  and  the  muscu- 
lature of  the  gall  bladder,  attempting  to  force  it  on,  is  thrown 
into  a  series  of  painful  sj^asms. 

In  gall-bladder  colic  the  pain  is  generally  sudden  m  its  onset 
and  persists  for  some  time,  when  it  either  gradually  fades  away, 
or,  owing  to  the  passage  of  the  stone  or  the  removal  of  the  duct 
obstruction,  it  disappears,  sometimes  quite  suddenly.  In  either 
case  it  leaves  a  legacy  of  tenderness  over  the  site  of  the  lesion. 

Over-distention  of  the  gall  bladder  may  occur  from  obstruc- 
tion of  the  cystic  or  common  duct  by  (a)  inflammation,  (b)  stone, 
(c)  pancreatic  lesions,  (d)  pressure  from  adjacent  viscera,  (e) 
tumors,  or  (f)  excessive  contraction  of  the  muscular  coat.  The 
gall  bladder  is  similar  to  many  other  abdominal  viscera  in  the 
method  of  its  pain  production.  This  pain  is  of  a  colicky  character, 
and,  at  the  time  of  its  production,  palpation  in  the  gall  bladder 
region  will  reveal  a  hard  tumor  mass,  due  to  a  spasmodic  muscular 
contraction  of  the  gall  bladder.  Should  this  spasmodic  muscular 
contraction  be  relieved,  either  because  of  the  opening  of  the  gall 
duct  passages  or  of  exhaustion  of  the  musculature,  the  pain  will  be 
eased  and  the  hard  tumor  mass  will  disappear.     If  the  bladder  is 


GALL   BLADDER  563 

not  emptied  the  mass  persists,  but  soon  loses  its  hard  con- 
sistency. 

One  of  the  commonest  lesions  of  the  gall  bladder  is  inflam- 
mation. In  addition  to  the  local  pains  (the  result  of  local  j)erito- 
nitis),  inflammation  of  the  gall  bladder  causes  well-marked  re- 
ferred pains.  The  inflammation  is  generally  of  a  very  active 
type  and  is  very  violent.  It  j^roduces  a  well-marked  tenderness. 
If  this  tenderness  suddenly  becomes  general  and  is  associated  with 
signs  of  a  spreading  peritonitis,  perforation  of  the  gall  bladder 
should  at  least  be  thought  of  and  searched  for.  Inflammation 
of  the  gall  bladder  (cholecystitis)  is  invariably  due  to  infec- 
tion. 

The  common  causes  of  gall-bladder  infection,  probably  in  the 
order  of  their  frequency,  are  colon  bacillus,  typhoid  bacillus,  and 
influenza  bacillus.  The  pneumococcus  and  tubercle  bacilli  are 
only  rarely  found  as  causative  agents.  Pregnancy  seems  espe- 
cially to  be  a  predisposing  factor  for  gall-bladder  infection.  Diar- 
rhea is  a  prominent  symptom  of  infection  of  the  bile  passages.  It 
occurs  after  eating  or,  in  some  cases,  in  the  middle  of  a  meal.  At 
the  time  of  the  diarrhea  severe  pain  is  felt  in  the  epigastrium. 
This  pain  is  probably  synchronous  with,  and  due  to,  the  contrac- 
tion of  and  the  emjDtying  of  the  gall  bladder. 

Following  the  inflammation  adliesions  form,  but  these,  unless 
they  are  attached  to  the  anterior  abdominal  wall,  are  not  particu- 
larly painful.  Should  they  be  so  attached  breathing  becomes  very 
painful,  and  the  pain  is  of  a  dragging  character.  Should  adhe- 
sions exist  between  the  gall  bladder  and  the  stomach  or  duodenum, 
the  pains  are  associated  with  digestive  activity.  In  these  cases 
there  is  some  history  of  a  previous  acute  attack,  in  which  the  pain 
was  confined  to  the  gall-bladder  region. 

Diagnosis. — The  means  of  eliciting  gall-bladder  pain  are 
palpation  and  percussion.  Tenderness  on  palpation  is  generally 
most  pronounced  beneath  the  costal  margin  at  the  level  of  the 
ninth  or  tenth  costal  cartilage.  There  is  here  present  a  point  of 
most  exquisite  tenderness,  and  around  this  an  area  which  is  not 
quite  so  tender.     In  some  cases,  where  there  is  an  associated  ap- 


564 


THE   LIVER,    GALL   BLADDER   AND    DUCTS 


pendix  involvement,  the  hyperesthesia  extends  down  to  the  neigh- 
borhood of  the  aj)pendix,  over  which  there  is  another  point  of 
maximum  tenderness. 

In  lesions  of  the  gall  bladder,  if  pressure  or  percussion  is  ap- 
plied over  any  portion  of  the  abdomen,  the  pain  is  felt  in  the 


Area  of  greatest  tender- 
ness in  cholelithiasis 

General  area  of  tender- 
ness in  cholelithiasis 
and  appendicitis 


Area  of  greatest  tender- 
ness in  appendicitis 


Fig.  126. — Area  of  Greatest  Tenderness  in  Diseases  of  the  Gall 
Bladder  and  Appendix. 

The  upper  X  indicates  the  point  of  maximum  tenderness  in  gall-bladder 
inflammation;  the  lower  X  that  of  the  appendix.  In  both,  though  the 
entire  area  indicated  may  be  tender,  the  points  of  maximum  tender- 
ness will  differentiate  the  two  disorders. 


gall-bladder  area  or  region.     This  is  one  method  of  differentiating 
gall-bladder  disease  from  appendicitis. 

For  the  purpose  of  differentiating  gall-bladder  (direct)  tender- 
ness from  that  due  to  lesions  of  other  organs,  Murphy  elaborated 
a  special  technique.  His  method  of  eliciting  the  tender  points  in 
gall-bladder  disease  is  as  follows :  Having  previously  removed 
all  clothing  from  the  part  to  be  examined  or  from  its  neighbor- 
hood, place  the  patient  in  a  sitting  position,  bent  well  forward, 
with  his  hands  resting  upon  his  knees.  The  examiner  now  stands 
behind   the  j^atient  and   places  his   hand,   with  the    palm   flatly 


DIFFERENTIAL  DIAGNOSIS.    DISEASE  OF  THE  LIVER  AND  ITS  APPENDAGES 


Symptom 

Hepatitis               '               Perihepatitis 

Gall  Bladder 

Gall  Duct 

G^™,cU.c.n 

Pyloric  Spasm 

Pancreatitis 

Renal  Colic 

Appendicitis 

Pain,  type. 

Dull     aching,     constant. 
Referred    areas    may    be 
present. 

More  sharp  than  in  hepatitis, 
increased    on    breathing,    on 
movement     and     on     sitting 
down  with  the  knees  drawn 
up.     Rub  present  on   palpa- 
tion and  friction  sound  pres- 
ent on  auscultation  over  the 
liver  region. 

Colic,  ^generally  of  a  paroxysmal 
type,     suddenly     reaching     an 
acme  and  then  suddenly  disap- 
pearing, leaving  only  a  feeling 
of  soreness  in  its  place.     In  some 
cases  instead  of  being  paro.xys- 
mal  the  pain  may  be  constant. 
Long  intervals  of  freedom  from 
pain  may  be  present. 

Generally   some   constant  sore- 
ness in  cholangitis,  then,  as  the 
duct  becomes  blocked,  the  pain 
is   paroxj-smal   with   a   gradual 
disappearance,  only  a  soreness 
remaining.     The  pain   may  be 
referred  to  the  area  of  the  fourth 
costal  cartilage  on  the  left  side. 
Long  intervals  from  pain  may 
be  present. 

Sudden,  sharp,  referred  to  one 
special  point  on  the  abdomen. 
Reheved  by  vomiting;  is  rather 
constant,  always  follows  the 
ingestion  of  food. 

Sudden  onset,  occurs  a  few  hours 
after  the  ingestion  of  food,  when 
it  is  passing  through  the  pylorus. 
The  spasm  is  relieved  by  Vomit- 
ing.   Attacks  generally  occur  at 
short  intervals. 

Principally  in 
epigastrium. 
Very  severe. 

Generally  sudden  onset. 
Radiates  down  the  groin 
in  the  direction  of  the  ure- 
ter, sometimes  as  far  as 
the  testicle.    Attacks  arc 
spasmodic  and  there  may 
be  a  long  period  of  free- 
dom between  individual 
attacks. 

May  in  case  of  coUc  be  of  sudden 
onset.    Finally  is  localized  to  the 
right  inguinal  fossa.      At  first, 
because  of  the  locaUzation  of  the 
appendix   pain   in    the   epigas- 
trium, it  may  be  confused  with 
cholecystitis.     In    some   cases, 
gall-stone  eoUc  may  be  confused 
with  appendiceal  colic. 

Relationship  lo 
the  ingestion  of 
food. 

Worse  at  the  time  of  in- 
testinal   digestion    when 
the  blood  content  of  the 
liver  is  greatest. 

Same  as  in  hepatitis. 

No  special  relationship  to  the 
ingestion  of  food. 

None  except  in  cases  of  inflam- 
mation of  the  duct  (common), 
when   it  seems   that  intestinal 
peristalsis  may  set  up  an  asso- 
ciated peristalsis  in  the  duct. 

Follows  immediately  upon  or  a 
short  time  after  the  ingestion  of 
food,  depending  upon  whether 
the  ulcer  is  at  the  cardia  or  the 
pylorus.  Eased  by  local  anal- 
gesics. 

Follows  two  to  four  hours  after 
the  ingestion  of  food. 

No  special  rela- 
tionship in  the 
acute  variety, 
but  in  chronic  is 
made  worse  by 
the  ingestion  of 
food. 

No  relationship. 

May  follow  four  to  eight  hours 
after  taking  food.    Rather  eom- 
nion  during  the  night. 

Tenderness. 

Present  over  liver  region. 

Present  over  liver  region. 

Present    over    margin    of    gall 
bladder.     Murphy's  sign   pres- 
ent. 

Shght  tenderness  in  epigastrium, 
then  over  the  gall  bladder  and 
liver  area,  as  the  duct  becomes 
occluded  and  the  gall  bladder 
and  liver  distended. 

Present  in  a  circumscribed  area. 
.\rea  is  constant,  and  is  generally 
located  in  the  epigastrium  im 
mediately  below    the    ensiform 
cartilage. 

In  epigastrium. 

Epigastric. 

Over   the   kidney   region  1  Over  McBumev's  point, 
in  the  loin. 

Jaundice.                 May  be  present. 

.\bsent. 

Ab.sent. 

Present. 

Absent. 

.\bsent. 

SUght     amount 
may  be  present. 

Absent.                                1  Absent. 

Nausea   and          Not  specially  marked, 
vomiting. 

Not  specially  marked. 

Generally  present.    May  be  con- 
stant and  severe.    Bile  present. 

Generally  present,  constant.  Bile 
is    present    when    the    duct    is 
blocked.  May  ease  the  pain. 

Generally  occurs.  Some  blood  in 
it  at  times;  the  pain  is  generally 
eased  by  it.    Bile  present. 

Frequent;   eases   the   pain;   no 
bile. 

Present  and,  as  a  ,  Not  so  common, 
rule,  persistent. 
Bile    generally  | 
present. 

Nearly  always  present. 

Temperature. 

SUght  rise. 

Slight  rise. 

Septic  in  cases  of  inflammation. 
In  cases  of  colic  no  rise. 

May  have  a  Charcot's  intermit- 
tent fever,  but  generally  no  rise 
in  gall  stone  colic  and  only  a 
slight  rise  in  cholangitis. 

No  rise. 

No  rise. 

Rise    or  if    the 
shock  be   too 
great  a  fall. 

Nu  rise. 

Rise,  if  the  severity  of  the  dis- 
ease increases,  the  temperature 
continues  to  rise  and  may  assume 
a  septic  t>'pe,  if  abscess  forma- 
tion results. 

Pulse. 

Slight  increa.'ff . 

Slight  increase. 

Considerable  increase  in  cases  of 
inflammation ;    very    slight,     if 
any,  increase  in  cases  of  colic. 

Generally  slight  increase. 

Shght  increase. 

Shght  increase. 

Very  rapid. 

Generally  rapi<l. 

Increased  in  rapidity. 

Urine. 

Bile  may  be  present. 

No  bile. 

No  bile. 

Bile  present. 

No  bile. 

No  bile.                                                  Glycosuria,    n  o 
1  bile. 

No  bile,  but  blood  and  pus. 

Generally  no  bile. 

Position  of  elec- 
tion. 

Pain   worse   when  lying 
on  left  side. 

On  back;  breathes  very  easy. 

Generally  on  back,  knees  drawn 
up,  abdomen  relaxed  as  njuch 
as  possible. 

Gall    stone    colic,    patient    is 
doubled  up.  with  knees  flexed  on 
abdomen,  body  bent   forward, 
and  pillow  or  hands  often  placed 
against  abdomen.  Patient  often 
hes  on  his  face. 

Back. 

.\ny  position. 

On  back. 

On  back,  with  the  knee  of 
the  affected  side  flexed  on 
the  abdomen.. 

Dorsal,  limbs    drawn    up,    and 
thighs  flexed  on  the  abdomen. 

Effect  of  move- 
ment. 

Increases  pain. 

Increases  pain. 

Increases  pain,  except  in  colic. 

Patient  is  very  restless;  constant 
'movement. 

Restless. 

Very    restless;    hands    pressed 
tightly  against  the  abdomen. 

Increases  pain. 

Not  much  effect.  Patient 
himself  is  very  restless. 

Very  quiet.    When  peritoneum  is 
involved, respiration  is  restricted. 

Application  of 
heat  or  cold. 

Cold  eases  pain. 

Cold  eases. 

Inflammation,   cold  eases,  heat 
increases.    Colic,  cold  increases, 
heat  eases. 

Same  as  in  gall  bladder. 

Cold  eases. 

Cold  increases,  heat  eases. 

Cold  eases   and 
heat  increases. 

Heat  eases. 

Cold  eases.     Heat  increases  at 
times. 

Referred  areas. 

For  referred  areas  see  un- 
der the  separate  lesions. 

For  referred  areas  see  under 
the  separate  lesions. 

For  referred  areas  see  under  the 
separate  lesions. 

For  referred  areas  «ee  under  the 
separate  lesions. 

For  referred  areas  see  under  the 
separate  lesions.    • 

For  referred  are-     For  referred  ar'eas  see  Un- 
as see  under  the  1  dcr  the  .separate  lesions, 
separate  lesions.  , 

Lower  than  in  gall  bladder  or 
duct  disease. 

lymptonid  closely  rt?jemble  those  of  gastric  ulcer,  fnira  which  it  !«boiiId  l)o  dilTei 

alilies  of  mucua  in  the  stools. 

id  the  patient  generally  gives  a  history  of  working  with  paints. 


,cd.     In  it  the  paio  c 


X  couple  of  hours  after  eating;  is  relieved  both  by  eating  and  by  v 


GALL    BLADDER 


565 


against  the  abdomen,  immediately  below  the  ribs  on  the  right  side. 
Have  the  patient  take  deep  breaths.  After  each  expiration  the 
examiner's  hand  follows  the  abdominal  wall  until  it  approaches 
closely  to  the  affected  gall  bladder  and  adjacent  tissues,  when  sud- 
denly the  respiration  ceases  with  a  gasp  and  the  patient  complains 
of  severe  pain.     This  indicates  that  the  hand  has  come  into  contact 


Fig.  127. — Method  op  Eliciting  Gall-Bladder  Tenderness. 


with  the  inflamed  tissues.     Naunyn's  sigTi  as  given  by  Da -Costa 
is  very  similar. 

Tenderness  at  Mayo  Robson's  point  is  also  supposed  to  indi- 
cate inflammation  of  the  gall  bladder  or  ducts.  This  tenderness 
lies  along  a  line  extending  from  the  tip  of  the  ninth  costal  carti- 
lage to  the  umbilicus.  The  point  of  greatest  tenderness  is  known 
as  Robson's  point,  and  is  situated  one  inch  to  the  right  of  the 
umbilicus. 


566 


THE    LIVER,    GALL    BLADDER    AKD    DUCTS 


Percussion  as  a  means  of  eliciting  pain  lias  been  discusseJ 
under  the  general  consideration  of  liver  j^ains. 

Radiation  of  Pain. — In  gall-bladder  disease  the  patient  fre- 
quently complains  of  pain,  wliicli,  according  to  Schmidt,  may  ex- 
tend to  the  right  nipple  and  backward  into  the  shoulder  blade, 
and  thence  into  the  lumbar  region.  This  radiation  is  more  fre- 
quent in  the  presence  of  an  associated  perihepatitis.  Associated 
jDains  in  the  lower  extremities  may  bo  the  result  cither  of  a  neu- 
ralgia or  a  septic  thrombus  (iliac  or  femoral).  Pains  in  the  left 
arm  may  be  symptomatic  of  a  true  angina  j^cctoris,   induced  by 


Fig.  128. — Radiation  of  Gall-Bladder  Pain  as  Given  by  Schmidt 

(p.  210). 


the  high  blood  pressure  caused  by  the  vesicular  pain.  Schmidt 
also  claims  that  radiation  of  pain  into  the  genitals  with  retention 
of  urine  may  occur.  Such  a  condition,  however,  is  rare  and,  when 
it  does  occur,  is  generally  due  to  peritonitis.  That  such  pain  ever 
occurs  wuthout  some  associated  complication  or  some  concomitant 
disease  is  doubtful. 

Radiation  into  the  right  iliac  fossa  sometimes  occurs,  and  it 
is  very  apt  to  lead  to  a  diagnosis  of  appendicitis.  In  fact,  in 
many  of  these  cases,  an  appendix  inflammation  is  associated  with 
the  gall-bladder  disease. 


GALL   BLADDER  567 

Pain  referred  to  a  distance  is  seldom  found  in  diseases  of  the 
gall  bladder  except  in  neurasthenic  patients.  In  the  neuras- 
thenic all  manner  of  pains  are  complained  of,  in  addition  to 
the  original  pains  of  the  gall-bladder  inflammation.  An  example 
of  this  was  had  in  the  case  of  a  patient  who  complained  of  pain 
over  the  spine,  in  the  right  leg,  and  the  back  of  the  head.  At 
the  same  time  there  were  tenderness  and  pain  in  the  epigastrium 
and  around  the  umbilicus. 

The  location,  direction  aaid  radiation  of  pain  produced  by 
pressure  will  frequently  help  to  differentiate  gall-bladder  pains 
from  those  due  to  disease  of  the  kidney,  duodenum,  or  stomach. 
If  the  gall  bladder  is  inflamed,  pressure  over  it  will  cause  pain  to 
appear  in  the  right  shoulder  and  in  the  epigastrium,  to  the  right 
of  the  median  line,  while,  in  the  other  diseases  mentioned  above, 
the  pain  will  appear  in  their  respective  associated  areas. 

It  is  sometimes  difficult  to  distinguish  the  tenderness  due  to 
disease  of  the  gall  bladder  from  that  due  to  disease  of  the  ap- 
pendix. An  aid  to  diagnosis  is  that  in  disease  of  the  gall  bladder 
the  segment  of  the  rectus  muscle  over  the  gall  bladder  is  in  a  state 
of  contraction,  while  the  segment  over  the  appendix  may  be  flac- 
cid. Another  point  of  differentiation  is  that  in  gall-bladder  in- 
volvement the  maximum  point  of  tenderness  is  at  the  junction  of 
the  ninth  or  tenth  costal  cartilages  with  the  costal  arch,  while  in 
appendicitis  the  area  of  greatest  tenderness  is  at  a  point  about 
midway  on  the  line  joining  the  umbilicus  to  the  anterior  superior 
spine  of  the  ilium. 

Reflex  Tenderness. — It  is  claimed  by  Schmidt  that  in  gall- 
bladder disease  there  is  a  "point  of  sensitiveness  along  the  upper 
portion  of  the  trapezius  muscle  about  three  fingers'  breadth 
distant  from  the  acromion.  Pressure  at  this  point  causes  pain 
which  radiates  to  the  gall  bladder;  and,  vice  versa,  pressure  over 
the  gall  bladder  causes  pain  that  radiates  to  this  area."  He  like- 
wise claims  that  these  conditions  are  found  in  liver  abscess  and 
in  subphrenic  inflammations.  They  seem  only  to  be  associated 
with  diseased  processes  in  which  the  diaphragm  is  involved.     The 


568  THE   LIVER,    GALL    BLADDER    AND    DUCTS 

vertebrae  between  the  fourth  and  twelfth  thoracic  may  be  tender 
on  pressure. 

Diseases  Causing  Pain. — Gall-bladder  colic  is  a  term  given  to 
the  pain  produced  by  an  over-distention  of  the  gall  bladder  from 
any  cause.  But,  as  long  as  drainage  from  the  gall  bladder  is  free, 
viz.,  as  long  as  the  cystic  and  common  ducts  are  free,  there  will 
be  no  pain.  However,  should  the  cystic  or  the  common  ducts  be- 
come occluded,  pain  immediately  ensues.  Since  the  causes  of  the 
blocking  of  these  ducts  will  at  the  same  time  be  the  causes  of 
gall-bladder  pain,  it  behooves  us  to  study  them  well.  The  com- 
mon causes  of  blocking  of  the  ducts  may  be  arranged  in  three 
groups,  namely:  (1)  intramural,  in  which  the  obstruction  is  due 
to  a  foreign  body,  such  as  a  gall  stone  or  an  ascaris;  (2)  intra- 
mural, such  as  inflammation  and  new  gi"owths,  the  inflammation 
causing  the  stenosis  may  occur  at  any  point  along  the  course  of 
the  bile  pathways,  may  be  local  to  the  ducts,  or  may  be  an  exten- 
sion of  any  inflammation  from  the  duodenum,  ascending  through 
the  papilla  of  Vater  into  the  biliary  system,  or  the  inflammation 
may  be  confined  to  the  ducts,  new  growths  arising  de  novo  in  the 
walls  of  the  bile  passages  are  extremely  rare;  (3)  extramural, 
such  as  kinks,  adhesions,  pressure  from  adjacent  organs  or  tumors. 
Any  of  these,  by  temporarily  shutting  oft"  the  exit  of  bile,  may  be 
the  cause  of  temporary  distention,  and  give  rise  to  colic. 

In  some  cases  gall  stones  may  be  present  without  causing  colic ; 
but  this  happens  only  when  the  gall  stones  have  been  present  for 
some  time  and  the  gall  bladder  and  ducts  have  accommodated 
themselves  to  their  presence.  The  presence  of  stones  in  the  gall 
bladder,  in  the  absence  of  pain,  is  very  common  in  enteroptosis, 
in  which  case  the  patient  may  complain  only  of  dyspeptic  symp- 
toms and  some  soreness  in  the  epigastrium. 

When  gall-bladder  colic  occurs  it  resembles  other  colics  in 
that  there  is  a  period  of  distress  followed  by  a  period  of  freedom, 
and  this  in  turn  is  followed  by  pain  which  gradually  increases  to 
the  maximum,  then  gradually  decreases  until  the  patient  is  again 
free  from  pain  (intermission).  Again,  the  pain  commences,  and 
at  first  is  of  slight  intensity  and  then  gradually  increases  to  the 


GALL   BLADDER  569 

maximum  and  gradually  decreases  to  the  minimum.  (See  Varie- 
ties of  Pain,  Colic.)  In  many  cases  gall  stones  cause  small  abra- 
sions on  the  vesicular  mucous  membrane,  and  these  permit  the 
entrance  of  bacteria,  which  give  rise  to  inflammation,  so  that  the 
pain  of  colic  is  frequently  associated  with  the  pain  of  cholecystitis 
(q.  v.). 

In  some  cases  intestinal  colic  has  been  mistaken  for  biliary 
colic.  However,  biliary  colic  can  be  diagnosed  by  the  tendency  of 
the  pain  of  intestinal  colic  to  migrate  and  to  localize  itself  in 
different  segments  of  the  abdomen,  depending  upon  the  location 
of  the  muscular  spasm  in  the  intestine. 

Cholecystitis. — The  pain  of  cholecystitis  is  of  two  types:  (a) 
paroxysmal  and  (b)  constant. 

The  paroxysmal  pain  is  most  likely  to  be  associated  with  the 
occasional  passage  of  a  gall  stone.  When  present  it  indicates  that 
the  duct  is  intermittently  blocked.  This  blocking  may  be  due 
either  to  a  stone  or  to  swelling  of  the  mucous  membrane.  Should 
the  duct  become  permanently  closed,  the  pain  becomes  constant, 
owing  to  the  continual  effort  of  the  gall  bladder  to  empty  itself. 

Constant  pain  is  also  an  indication  that  the  inflammation 
which  is  present  has  spread  to  the  peritoneal  coat  and  has  in- 
duced a  peritonitis.  When  tlie  inflammation  has  been  active  for 
some  time  the  accumulation  of  biliary  secretion  in  the  gall  blad- 
der may,  if  the  duct  becomes  occluded,  cause  a  distention  of 
that  organ  and  thus  produce  pain.  However,  this  obstruction 
must  be  in  the  cystic  duct,  and  must  also  be  sudden  in  onset. 
Otherwise,  the  gall  bladder  accommodates  itself  to  the  distention 
without  pain  production. 

In  every  case  when  the  duct  is  occluded,  in  addition  to  pain 
and  tenderness,  a  tumor  mass  is  formed.  The  size  of  this  mass 
varies  and  seems  in  some  instances  to  depend  upon  the  alternate 
distention  and  emptying  of  the  gall  bladder.  The  common  cause 
of  such  a  state  is  a  gall  stone  having  a  ball-valve  action,  or  a  kink, 
which  can  be  straightened  by  the  pressure  of  the  bile  posterior  to 
it.  In  both  cases  the  passage  of  the  bile  is  followed  by  the  relief 
of  the  pain,  which  reappears  on  the  reformation  of  the  tumor. 


570  THE   LIVER,    GALL   BLADDER   AND    DUCTS 

This  tumor,  whicli  is  formed  by  the  distended  gall  bladder,  is 
freely  movable  from  side  to  side,  and  follows  the  inspiratory 
movements  of  the  liver.  Temperature  elevation  and  increase  of 
pulse  rate  accompany  this  condition.  Jaundice  seldom  oc- 
curs. Clay-colored  stools  may  be  present,  and  nausea  and  vomit- 
ing are  frequent.  A  symptom  gi-oup  of  this  description  indicates 
a  recurring  cholelithiasis,  from  which  a  cholecystitis  has  arisen. 
When  the  tenderness  suddenly  increases,  becomes  more  acute,  and 
is  associated  with  vomiting,  it  most  commonly  indicates  the  begin- 
ning of  a  local  peritonitis. 

If  the  primary  pain,  which  may  have  been  either  constant  or 
intermittent,  suddenly  becomes  most  severe,  with  increasing  ten 
derness,  or  if  the  tenderness  shows  a  tendency  to  spread,  and  if, 
at  the  same  time,  there  is  an  increasing  rigidity  of  the  upper 
abdomen,  a  diagnosis  of  gall-bladder  perforation  is  justifiable. 

Deaver,  in  speaking  of  cholecystitis,  says  that  the  "pain  is 
situated  in  the  epigastric  region,  is  usually  sharp,  appears  sud- 
denly or  gradually,  and  is  increased  by  motion  of  the  entire  body 
or  of  a  regional  organ,  such  as  may  be  made  by  the  stomach,  in 
peristalsis  or  in  vomiting."  He  further  states  that  in  the  absence 
of  peritonitis  '"the  accompanying  tenderness  indicates  the  situa- 
tion of  the  gall  bladder,  and  the  presence  and  extent  of  peritoneal 
irritation  or  of  peritonitis  are  indicated  by  the  extent  of  the  asso- 
ciated tenderness." 

The  pain  and  tenderness  of  cholecystitis  are  generally  asso- 
ciated with  rigidity  of  the  abdominal  muscles.  There  is  a  rigidity 
of  the  rectus  abdominis  on  the  right  side,  localized  to  the  diseased 
area;  and,  as  the  disease  advances,  this  rigidity  increases  pari 
passu  with  it.  Finally,  if  a  generalized  peritonitis  results,  all 
of  the  abdominal  muscles  become  contracted. 

In  all  inflammatory  lesions  of  the  gall  bladder  deep  breath- 
ing is  painful.  Pain  also  results  if  the  inflamed  and  sensitive 
peritoneum  of  the  gall  bladder  is  pressed  against  adjacent  struc- 
tures, as  the  stomach,  the  colon,  and  the  anterior  abdominal  wall. 
Movement  of  any  kind  (walking,  running,  or  even  bending  over 
so  that  the  intraabdominal  contents   are  on  the  stretch)    causes 


GALL   BLADDER  571 

pain.  Should  the  inflammation  have  spread  to  the  adjacent  liver 
tissue  a  friction  rub  can  be  heard  on  auscultation,  and  sometimes 
can  even  be  felt  on  palpation. 

Cholecystitis  m.aj  be  mistaken  for  a  movable  kidney;  but  the 
elevation  of  temperature,  the  increased  leukocyte  count,  pain  in 
the  prone  position,  and  the  location  of  the  local  tenderness  and 
its  radiation,  in  cholocystitis  should  differentiate  this  from  the 
movable  kidney.  However,  in  many  cases  of  cholecystitis  pain 
may  be  entirely  absent.  That  this  is  not  by  any  means  uncom- 
mon can  be  deduced  from  the  evidence  furnished  at  autopsy, 
where  old  and  chronic  inflammations  of  the  gall  bladder  are 
found,  with  an  absolutely  negative  history  of  a  gall-bladder  infec- 
tion. If  the  gall  bladder  is  in  close  relation  to  the  appendix,  in- 
flammation of  it  may  induce  an  infection  of  the  adjacent  appendix, 
and  so  cause  appendicitis.  This  can  happen  only  in  very  severe 
cases  of  cholecystitis  when  the  peritoneum  is  diseased,  and  only 
so,  if  this,  in  continuity  or  contigiiity,  affects  the  serous  coat  of 
the  appendix.  This  secondary  appendicitis  may  so  divert  the  at- 
tention as  to  cause  us  to  overlook  the  serious  gall-bladder  involve- 
ment. 

New  Growths. — The  new  growths  of  the  gall  bladder  may  be 
classed  as  malignant  and  benign. 

Malignant  growths,  of  which  carcinoma  and  sarcoma  are  the 
chief,  if  not  the  only,  representatives,  are  generally  the  cause  of 
at  least  some  pain  and  discomfort.  At  first  the  sensation  is  more 
like  an  unrest  or  a  vague  distress  referred  to  the  area  of  dis- 
tribution of  the  seventh  or  eighth  dorsal  segments,  which,  accord- 
ing to  Head,  are  most  commonly  affected,  though  other  segments, 
as  the  fifth  and  sixth,  are  also  very  likely  to  be  involved.  By 
means  of  this  referred  sensation,  which  later  may  increase  to 
actual  pain,  it  is  very  difficult  to  differentiate  gall-bladder  from 
liver  disease,  as  the  relationship  between  the  two  is  so  intimate 
that  diseases  affecting  the  gall  bladder  generally  at  the  same  time 
produce  reflex  disturbances  in  the  liver ;  hence  it  is  next  to  impos- 
sible for  a  lesion  of  the  gall  bladder  to  be  present  without  pro- 
ducing some  associated  disorder  in  the  liver.     Should  well-marked 


572  THE   LIVER,    GALL   BLADDER   AND    DUCTS 

pain  be  felt,  localized  to  the  region  of  the  gall  bladder  (see  fig- 
ure), and  a  tumor  mass,  tender  on  pressure,  be  detected,  together 
with  cachexia  and  emaciation,  it  is  a  fairly  good  indication  that 
malignant  disease  of  the  gall  bladder  is  present.  Xew  growths, 
however,  do  not  always  give  rise  to  pain,  for,  in  many  cases,  the 
growths  are  latent  and  produce  no  complaints  until  the  tumor 
cells  begin  to  invade  the  adjoining  structures.  When  this  occurs 
the  symptoms  of  the  gall-bladder  involvement,  which  may  have 
been  so  vague  and  indefinite  that  they  previously  were  imnoted, 
become  of  diagnostic  value. 

ISTon-malignant  growths  of  the  gall  bladder  are  generally  pain- 
less. Under  non-malignant  growths  are  included  hydatid  cyst, 
papilloma,  adenoma,  fibroma,  and  fatty  cysts- 
New  growths  of  the  gall  bladder  are  sometimes  confused  with 
tumors  of  the  hepatic  flexure  of  the  colon;  but  these  latter  can 
generally  be  differentiated  by  the  presence  of  signs  of  intestinal 
obstruction.  The  range  of  motion  and  the  arc  of  rotation  in 
tumors  of  the  colon  is  different  than  in  tumors  of  the  gall  bladder ; 
however,  owing  to  adhesions,  which  may  coexist  with  the  two 
growths,  it  is  often  very  difficult  to  make  a  positive  diagnosis. 

Hysteria  often  produces  a  set  of  symptoms  that  resemble  gall- 
bladder colic.  Here  it  is  extremely  hard  to  make  a  diagnosis, 
but  perhaps  if  we  remember  that  in  nearly  all  cases  of  hysteria 
there  is  some  basis  for  the  pain  phenomena,  the  diagnosis  will  be 
far  easier.  In  ninety-nine  cases  out  of  a  hundred  a  diagnosis  of 
hysteria  will  be  found  to  be  incorrect. 

GALL-DUCT   PAIN 

Etiology. — Gall-duct  pain  is  due  to  two  causes:  (a)  obstruc- 
tion of  the  ducts,  and  (b)  inflammation  of  the  ducts,  with  exten- 
sion of  the  inflammation  to  the  adjacent  peritoneum. 

Obstruction  of  the  ducts  invariably  leads  to  gall-duct  colic, 
and,  if  the  obstruction  persists,  may  end  in  gall-duct  inflammation 
(cholangitis).  The  latter  inflammation  may  spread  through  the 
wall  and  involve  the  peritoneum.  The  pain  of  peritonitis  is  now 
added  to  that  of  the  original  complaint.     The  causes  of  obstruction 


GALL-DUCT    PAIN  573 

of  the  gall  ducts  are:  intramural,  bj  foreign  bodies  (such  as  gall 
stones,  ascarides,  etc.)  ;  intcrmural,  as  inflammation  (cholangitis) 
and  new  growths ;  and  extramural,  by  new  growths,  kinks,  and 
adhesions. 

Pains  that  have  their  origin  in  the  ducts  may  be  classified  as : 

(a)  gall-duct  colics  from  gall  stones,  ascarides,  and  new  growths ; 

(b)  inflammation  pains  (cholangitis),  having  their  origin  from 
spread  of  inflammation  from  the  duodenum;  (c)  inflammation 
from  infection  with  bacteria  eliminated  by  the  liver;  (d)  inflam- 
mation due  to  infection  following  the  lodgment  of  gall  stones ;  and 
(e)  malignancy. 

Location  of  Pain. — The  pain  of  gall-duct  colic  is  sudden  in  its 
onset  and  is  located  in  the  epigastric  region.  In  some  cases  the 
pain  due  to  obstruction  of  the  common  duct  may  be  referred  to 
the  anterior  surface  of  the  chest  at  about  the  fourth  to  the  sixth 
left  costal  cartilages.  Pain  from  obstruction  of  the  cystic  duct 
may  be  referred  to  the  right  of  the  vertebral  column,  between  the 
eighth  and  eleventh  dorsal  vertebrte,  while  hepatic-duct  pain  may 
be  referred  to  the  right  hypochondrium,  to  the  thigh,  and  even  to 
the  head  and  neck.  In  some  cases,  owing  to  the  location  of  the 
pain  in  the  cardiac  region,  gall-duct  colic  has  been  mistaken  for 
angina  pectoris  (Hall).  In  other  cases  it  may  begin  in  the  epi- 
gastrium and  radiate  over  the  abdomen  to  the  right  subscapular 
region  and  has  even  been  felt  in  the  right  lumbar  region  (May- 
lard).  It  has  also  been  known  to  radiate  into  the  left  shoulder. 
"When  the  pain  in  its  onset  is  constantly  located  on  the  left  side, 
adhesions  to  the  stomach  are  generally  found. 

Character  of  the  Pain. — Gall-duct  colic  due  to  stone  is  gen- 
erally very  sudden  in  onset.  Sometimes  it  follows  the  ingestion 
of  food,  particularly  acid  drinks  or  alcoholic  beverages,  though 
the  attacks  may  ofccur  independently  of  the  taking  of  food.  It 
is  very  prone  to  occur  at  night,  four  to  six  hours  after  the  in- 
gestion of  the  last  meal.  The  colic  occurs  in  paroxysms,  follow- 
ing each  other  at  variable  intervals,  at  first  of  great  severity  and 
then  of  gradually  diminishing  intensity.  Between  the  paroxysms 
there  is,  in  the  gall-bladder  region,  a  constant  dull  aching  which  at 


574  THE   LIVER,    GALL   BLADDER   AND    DUCTS 

times  becomes  magnified  into  pain  of  great  severity.  The  cessa- 
tion of  the  paroxysms  generally  indicates  the  passage  of  the  stone, 
either  from  the  cystic  to  the  common  duct  or  from  the  common 
duct  into  the  duodenum ;  or  it  may  be  that,  owing  to  the  ball- 
valve  action  which  is  present,  the  stone  has  been  forced  back  to 
the  dilated  part  of  the  duct  or  to  the  gall  bladder.  The  first  at- 
tack of  biliary  colic  is  the  most  severe,  because  at  this  time  the 
duct  has  not  as  yet  been  dilated.  During  successive  attacks  it 
becomes  of  large  caliber,  the  stone  passes  through  more  easily, 
and  the  individual  attacks,  therefore,  are  of  less  severity.  An 
attack  generally  lasts  one  or  two  hours  and  ends  with  nausea  and 
vomiting.  The  nausea  and  vomiting  seem  to  relax  the  duct  and 
permit  the  more  easy  passage  of  the  stone. ^ 

After  the  painful  paroxysms  there  is  frequently  present  in  the 
upper  part  of  the  abdomen  a  dull  aching  which  persists  until 
the  next  attack  occurs.  In  some  cases  the  pain  becomes  more 
severe,  loses  its  spasmodic  character,  and  gradually  spreads  over 
the  upper  abdomen.  At  the  same  time,  epigastric  tenderness  is 
marked  and  abdominal  distention  occurs.  Here  we  are  dealing 
with  an  associated  peritonitis. 

Biliary  colics  often  come  on  without  any  apparent  active  ex- 
citing cause,  though,  as  stated  above,  they  are  often  associated 
with  the  ingestion  of  food  or  drink.  They  often  commence  after 
a  severe  spell  of  vomiting,  the  result  of  gastritis  following  an  in- 
discretion in  diet.  At  first,  on  the  entrance  of  the  stone  into  the 
duct,  the  pain  is  of  a  dull  character;  and  then,  owing  to  the 
movement  of  the  diaphragm  and  of  the  abdominal  wall,  the  gall 
stone  or  stones  are  forced  deeper  into  the  cystic  or  common  duct 
and  a  typical  gall-stone  colic  results.  The  pain  and  vomiting  of 
the  gastritis  now  merge  into  the  pain  and  vomiting  of  the  colic. 
This  seems  to  be  the  history  of  nearly  all  gall-stone  cases.  The 
stones  remaining  quiescent  in  the  gall  bladder  for  a  number  of 
years,  until  suddenly,  owing  to  forcible  movements  and  changed 

^  On  the  passage  of  the  stone  into  the  duodenum,  there  is,  according  to 
Keay,  a  peculiar  gliding  sensation  to  the  right  of  the  tenth  and  twelfth  dorsal 
vertebrae  (Kolleston,  p.  725). 


GALL-DUCT    PAIN  575 

relationship  of  the  viscera  in  the  abdominal  cavity,  they  are  dis- 
placed into  the  cystic  duct,  where  they  may  lodge  and  cause  the 
paroxysmal,  cutting  pain  which  is  so  distressing.  Below  is  a  cita- 
tion of  a  case  illustrating  how  this  occurs : 

In  this  patient  the  right  ovary  was  removed,  owing  to  its  cystic 
state.  The  history,  as  given  by  the  patient,  was  that  a  month 
after  recovery  from  typhoid  fever  she  was  taken  with  a  violent 
colic,  the  pain,  extremely  severe,  being  present  in  the  epigastrium. 
It  seemed  to  lie  in  the  mid-line,  a  short  distance  above  the  umbili- 
cus. Vomiting  was  severe  at  this  time  and  was  followed  by  diar- 
rhea. These  conditions  quickly  improved  and  the  patient  was  in 
fairly  good  health  with  the  exception  of  a  pain  in  the  back,  the 
continuity  of  which  (the  pain)  was  interrupted  by  paroxysms  of 
increased  intensity.  Three  weeks  after  this  first  attack  she  was 
again  indiscreet  in  her  diet  and  another  attack  of  acute  indiges- 
tion followed.  Vomiting  occurred,  all  of  the  stomach  contents 
were  expelled,  and,  though  the  stomach  was  washed  out,  nausea 
and  retching  still  continued.  The  pain  also  was  different.  In- 
stead of  being  in  the  median  line  and  slightly  above  the  umbilicus, 
it  was  more  to  the  right  and  immediately  below  the  costal  arch. 
It  seemed  to  run  directly  through  to  the  back.  It  was  extremely 
severe,  and  was  described  by  the  patient  as  being  sharp  and  break- 
ing in  character.  It  was  at  first  almost  continuous,  but  finally 
became  slightly  intermittent.  Localized  tenderness  was  present 
over  the  gall-bladder  region.  Operation  revealed  a  stone  occlud- 
ing the  cystic  duct. 

It  is  evident  that  gall-stone  colic  may  be  caused  by  the  lodg- 
ment of  calculi  in  either  the  cystic,  hepatic,  or  common  ducts. 
The  stone  or  stones  deposited  in  the  cystic  duct  are  generally  of 
large  size  and  the  colic  does  not  disappear  until  either  the  stone 
is  passed,  which  is  rare,  or  until  it  is  returned  into  the  gall  blad- 
der, which  is  more  common.  Before  this  takes  place  gall-bladder 
colic  occurs  as  a  complication.     The  same  holds  true  in  the  com- 


576  THE   LIVER,    GALL   BLADDER   AND    DUCTS 

mon  duct;  but  in  common-duct  colic  jaundice  comes  on  as  a  com- 
plication, while  in  c^'stic-duct  colic  it  is  absent.  Hepatic-duct 
stones  are  usually  small  and  resemble  gravel  very  closely,  so 
that  the  pain  is  not  so  acute  as  in  the  other  colics.  Examination 
of  the  feces  will  often  disclose  the  small  calculi.  X-ray  examina- 
tion may  determine  at  once  the  presence  and  position  of  the 
calculi.  However,  in  the  vast  majority  of  cases  the  X-ray  is  of 
little  value. 

More  or  less  cholecystitis  always  accompanies  all  gall  stones. 
In  fact,  it  is  the  inflammatory  process  which  is  responsible  for 
the  passage  of  the  calculus  out  of  the  gall  bladder,  so  that  fre- 
quently the  gall-duct  colic  follows  a  cholecystitis  (Rolleston).  In 
some  cases  a  gall  stone  becomes  impacted  in  the  cystic  or  common 
duct  and  pain  may  be  present,  intermittently,  for  weeks.  These 
attacks  are  often  associated  with  slight  temperature,  chills,  and 
an  increase  of  pulse  rate,  the  so-called  Charcot's  intermittent 
fever.  The  patient  is  generally  very  restless  and  throws  himself 
into  all  sorts  of  positions.  Tenderness  in  the  region  of  the  gall 
bladder,  according  to  Bishop,  is  invariably  present,  and  not  only 
is  found  during  an  attack,  but  persists  afterward,  and  can  always 
be  elicited  by  properly  applied  pressure. 

Associated  Symptoms. — Symptoms  associated  with  gall-duct 
colic  are  (a)  vomiting,  which  at  times  is  most  severe,  the  vomitus 
containing  no  bile,  which  likewise  is  characteristic  of  the  stools, 
which  are  light  in  color  and  of  a  very  disagreeable  odor ;  (b)  bili- 
rubin is  present  in  the  urine  and  it  leaves  yellow  marks  upon  the 
linen;  (c)  jaundice  is  also  present,  but  this  is  not  absolutely  char- 
acteristic of  gall-duct  colic,  as  it  is  also  sometimes  present  in  gas- 
tritis and  appendicitis,  in  duodenal  ulcer,  and  in  carcinoma  of 
the  hepatic  flexure;  (d)  temperature  elevation  is  usual  and  per- 
sists for  some  time  after  the  cessation  of  the  attacks.  The  rise 
of  temperature  is  generally  an  indication  of  the  presence  of  a 
localized  peritonitis.  Constipation  most  frequently  accompanies 
gall-duct  colic ;  when  diarrhea  is  present  it  is  a  probable  sign  that 
intestinal  complications  have  ensued.     As  a  result  of  the  pain  of 


GALL-DUCT    PAIN  •     577 

gall-stone   colic,    syncope    and   even   death   have  been   known   to 
occur.  ^ 

Differential  Diagnosis. — Gall-stone  colic  should  be  diagnosed 
from  (a)  gastric  ulcer,  (b)  floating  kidney,  (c)  renal  colic,  (d) 
appendicitis,  (e)  mucous  colitis,  (f)  hepatic  crises  of  tabes,  lead 
colic,  angina  pectoris,  gastric  ulcer,  malignant  diseases  of  the 
gall  ducts,  pancreatitis,  and  lumbago.  For  the  most  important 
of  these  differential  diagnostic  signs  see  Differential  Diagnosis 
of  Diseases  of  the  Liver. 

In  catairlial  cliolangltis,  pain,  as  a  rule,  is  absent ;  likewise 
there  is  no  tenderness.  This  difference  between  this  form  of 
jaundice  and  infective  and  calculus  jaundice  should  be  noted. 
Should  biliary  colic  supervene  during  the  course  of  a  simple 
catarrhal  jaundice  it  is  an  indication  that  the  gall  bladder  has 
become  infective  and  cholecystitis  has  supervened. 

Suppurative  Cholangitis. — In  this  disorder  pain  may  be  en- 
tirely absent.  When  present  it  m^y  be  due  to  an  extension  of 
the  inflammation  to  the  peritoneum,  causing  peritonitis.  This 
extension  occurs  directly  through  the  wall  of  the  ducts  or  extends 
through  the  liver  tissue  from  the  inflammation  located  at  the  ter- 
minal openings  of  the  ducts  in  the  liver.  Obstruction  of  the  bile 
ducts  may  occur  from  some  of  the  factors  which  were  the  original 
causes  of  the  inflammation,  such  as  gall  stones,  Avorms  (ascarides) 
in  the  ducts,  and  rupture  of  hydatids  into  the  ducts.  Malignant 
disease  may  also  cause  obstruction  and  produce  inflammation  and 
jaundice.  When  the  bile  ducts  are  obstructed  the  same  symptom- 
complex  is  present  as  is  found  in  duct  obstruction  from  any  other 
cause.  Should  ascarides  be  the  cause,  either  the  worms  or  the 
ova  may  be  found  in  the  stools. 

Cancer  of  the  biliary  passages  is  generally  first  announced  by 
icterus;  then,  as  the  lesion  progressively  increases  in  size,  infiltra- 
tion into  the  surrounding  ligaments  takes  place,  and  a  pull  may 
occur  on  the  peritoneum,  and  so  cause  pain.  This  pain,  though 
generally  secondary  to  the  jaundice,  may  be  primary  and  is  of  a 

^Eolleston,  "Diseases  of  the  Liver,  Gall  Bladder  and  Gall  Ducts,"  p.  725, 
quoted  from  AUbutt  in  "System  of  Medicine,"  Vol.  III.,  p.  47. 


578 


THE    LIVER,    GALL    BLADDER   AND    DUCTS 


dull,  aching  character.  It  is  nearly  always  present  and  is  found 
in  the  right  hypochondrium,  in  some  cases  in  the  left  epigas- 
trium. When  it  is  located  on  the  left  side,  the  adjacent  struc- 
tures, as  the  pancreas  (head)  or  the  pyloric  end  of  the  stomach  or 
duodenum,  are  involved.  Biliary  colic  is  sometimes  present  and 
may  be  due  to  the  presence  of  vesical  gall  stones.  In  other  cases 
no  gall  stones  are  found  and  the  colic  is  due  to  muscular  spasms 
in  the  walls  of  the  duct  from  irritation  by  the  malig-nant  growth. 
However,  carcinoma  of  the  gall  ducts  is  at  times  entirely  without 
pain.  This  occurs  when  the  obstruction  is  not  of  enough  magni- 
tude entirely  to  block  the  ducts.  Symptoms  indicative  of  malig- 
nant growths  of  the  gall  ducts  are  distention  of  the  gall  bladder, 
the  presence  of  a  tumor    in    the    epigastrium,    emaciation,  ^and 


DIFFERENTIAL  DIAGNOSIS,  GALL-BLADDER  COLIC 
AND  GALL-DUCT  COLIC. 


Symptoms 

Gall-Bladder  Colic 

Gall-Duct  Colic 

Pain. 

1 

More  severe  than  in  gall- 
duct  colic.  Not  so  frequently 
associated  with  digestion  as 
is  the  pain  of  gall-duct  colic. 
Referred  to  right  shoulder 
or  to  the  back  between  and 
below  the  scapuke. 

Less  severe.  Frequently 
associated  with  the  inges- 
tion of  food. 

Referred  to  the  left  side 
of  the  chest  about  the  line 
of  the  third  or  fourth  cos- 
tal cartilage. 

Jaundice. 

Generally  absent.     This  is 
especially  true  should  the 
cause    of    the    gaU-bladder 
colic  be  an  obstruction  in 
the  cystic  duct. 

Generally  present,  always 
so  if  the  obstruction  is  in 
the  common  or  the  he- 
patic ducts. 

Local  Tenderness 

Higher  iu  the  epigastrium 
and  more  toward   the  cos- 
tal arch  than  is  the  tender- 
ness  associated   with   gall- 
duct  colic. 

At  Mayo  Robson's  point. 

Vomiting. 

Common  and  continued  af- 
ter the  first  paroxysm. 
Generally  no  bile. 

Generally  present  at  first. 
No  bUe. 

Tumor. 

Always  present,  is  movable 
if  adhesions  are  not  present. 

No  tumor  present. 

Gall-bladder  and  gall-duct  coUc  are  often  so  intimately  associated  that  it  is 
very  difficult  to  distinguish  between  the  two.  The  gall-bladder  cofic  is  almost  an 
invariable  accompaniment  and  sequela  of  gall-duct  colic. 


GALL-DUCT    PAIN  579 

cachexia.  Jaundice,  which  gradually  becomes  more  intense  until 
it  is  dark  green  or  almost  black  in  color,  is  also  present. 

The  stools  are  free  from  bile  pigments,  though  bile  is  found 
in  the  urine.  Secondary  metastatic  growths  may  also  occur,  and 
when  found  make  certain  the  diagnosis  of  malignancy. 

The  pain  due  to  cancer  of  the  pancreas  is  different  from  that 
due  to  cancer  of  the  bile  ducts,  in  that  it  is  located  in  the  epi- 
gastrium, while  the  latter  is  in  the  hypogastrium.  However,  the 
two  conditions  are  very  hard  to  diagnosticate  from  each  other. 

Gall-stone  colic  differs  from  obstruction  colic  due  to  cancer  by 
the  onset  of  the  colic  before  the  appearance  of  the  jaundice.  Cour- 
voisier's  law  should  also  help  in  the  diagnosis ;  namely,  that  in 
calculus  obstruction  of  the  common  duct  the  gall  bladder  is  not 
enlarged,  while  in  obstruction  due  to  malignant  disease  of  the  com- 
mon duct  it  forms  a  well-defined  tumor. 


CHAPTER  XXVII 

•  THE  PANCEEAS 

GENERAL  CONSIDERATIONS 

It  is  only  recently  that  recognition  of  the  diseases  of  the  pan- 
creas has  emerged  from  the  deep  obscnrity  heretofore  existent. 
In  the  last  decade  or  two  that  organ  has  been  stndied,  its  diseases 
and  disorders  defined,  and  their  symptoms  arranged  and  classi- 
fied. Even  to-day,  however,  the  pathological  processes  are  still  a 
matter  of  considerable  conjcctnre  and  antopsy  often  discloses 
disease  which  the  clinician  has  been  unable  to  define.  But  as  the 
years  go  on  the  jiathology  and  the  symptomatology  are  gradually 
being  more  and  more  correlated,  until  to-day  we  have  much  more 
definite  knowledge  and  exact  means  for  diagnosing  pancreatic 
lesions. 

Symptoms  which  may  be  present  in  any  disease  are  only  of 
as  much  value  as  we  are  able  to  interpret  them  in  the  terms  of 
that  disease,  and  this  is  especially  true  of  pancreatic  pain,  for  it 
is  probably  more  difficult  in  many  cases  of  pancreatic  disorder 
to  determine  the  full  value  and  significance  of  pain  than  it  is  to 
interpret  any  other  of  the  pancreatic  symptoms.  So  much  reliance 
has  to  be  placed  upon  the  word  of  the  patient,  and  so  much  de- 
pendence upon  the  accuracy  of  his  interpretation,  that  it  is  very 
difficult  to  measure  the  full  extent  of  the  disorder  from  which  he 
suffers.  To  understand  thoroughly  the  pains  due  to  disease  of 
the  pancreas  and  the  method  of  their  production  and  radiation  it 
is  necessary  to  consider:  (1)  the  nerve  supply  of  the  pancreas; 
(2)  its  structure;  (3)  its  peritoneal  relations;  and  (4)  its  rela- 
tionship to  other  parts. 
580 


GENERAL    CONSIDERATIONS 


581 


Nerve  Supply. — The  nerve  stimuli  to  and  from  the  pancreas 
travel  through  both  cerebrospinal  and  sympathetic  fibers.  The 
cerebrospinal  filaments  are  the  vagi ;  the  left  vagiis  being  brought 
into  contact  with  the  pancreas  through  the  hepatic  and  splenic 
plexi,  while  the  right  communicates  with  the  hepatic  plexus, 
which,  through  the  pancreatico-duodenal  plexus,  supplies  the  right 
half  of  the  pancreas.  These  fibers  probably  convey  vasomotor 
and  secretory  impulses,  though  it  is  very  probable  that  both 
vagal  and  sympathetic  fibers  carry  painful  stimuli,  although  it  has 
been  held  that  it  is  mainly  through  the  splanchnics  that  painful 


Branch  to  left 
vagus 

Coronary  plexus 

Greater  splanch- 
nics 

Celiac  plexus 
Splenic  plexus  sup- 
plies   tail    of    pan- 
creas 


Branch  to  right 
vagus 


Hepatic  plexus 
Semilunar  ganglia 

Lesser  splanchnics 


Pancreatico- 
duodenal plexus 
supplies  head  of 
pancreas 


_  Sup.  mesenteric 
plexus 


Pancreas 


Branch    supplying    the 
right  half  of  pancreas 


Branch    supplying    the 
left  half  of  pancreas 


Fig.  129. — Nekve  Supply  to  Pancreas. 


stimuli  are  carried,  and  it  is  in  the  distribution  area  of  the  nerves, 
whose  centers  have  a  common  relationship  with  the  centers  for 
the  splanchnics,  that  pain  is  felt.  The  splanchnics  arise  from 
the  sixth  or  possibly  fifth  thoracic  sympathetic  ganglia  to  the 
twelfth  thoracic  ganglia.  These  ganglia,  in  turn,  are  connected 
with  the  corresponding  segments  of  the  cord  to  which  the  stimulus 
is  carried,  and  from  thence  reflex  sensatioud  are  referred  back  to 
the  abdominal  wall.  The  distribution  area  of  these  nerves  extends 
from  about  the  level  of  the  nipple  to  the  crest  of  the  ilium.  That 
the  pain  is,  in  most  cases,  referred  to  this  entire  area  cannot  be 
admitted,  because  nearly  all  the  cases  of  well-defined  pancreatic 
lesions  which  have  been  carefully  studied  do  not  show  such  wide 


582 


THE   PANCREAS 


distribution.  From  the  clinical  findings,  it  seems  that  possibly 
the  greater  splanchnic,  alone,  conveys  the  pain-producing  stimuli, 
for  it  is  in  the  distribution  areas  of  the  nerves  arising  from  the 
same  segment  of  the  cord,  to  Avhich  the  greater  splanchnic  is 
connected,  that  pain  is  felt.  According  to  Robson  and  Cammidge, 
the  nerves  accompany  the  arteries  to  the  gland,  in  the  substance 


Distribution  area  of  the 
5th  to  9th  intercostals 


Distribution  area  of  the 
9th  to  12th  intercostals 


Fig.  130. — Distribution  Areas  for  Pain  Due  to  Pancreatic  Lesions. 


of  which  they  travel  alongside  the  ducts,  and  terminate  around 
the  acini  in  a  rich  plexus  of  nerves  which  send  fibers  to  the 
secreting  cells. 

Thus  far  a  study  of  the  hyperesthetic  or  hyperalgesic  areas,  by 
Head's  methods,  in  pancreatic  atfections  has  not  been  made.  The 
presence  or  absence  of  these  zones  might  be  of  considerable  diag- 
nostic merit  should  they  be  studied  carefully  enough  to  make 
them  of  value.  Figure  130  only  indicates  in  a  general  way  the 
distribution  areas  for  pain  due  to  pancreatic  lesions. 

Structure  of  the  Pancreas. — The    structure    of   the   pancreas 


GENERAL    CONSIDERATIONS  583 

does  not  offer  any  special  facilities  for  pain  production  besides 
those  which  are  found  in  ordinary  secreting  glands.  All  glands 
have  one  or  more  ducts,  and  it  is  the  ducts  which  generally  are 
the  cause  of  the  ]3ain  phenomena.  Inflammation  occurs  in  the 
ducts,  producing  a  stenosis,  with  blocking  of  the  secretion,  and 
this,  leads  to  inflammation  in  the  gland  and  muscular  spasm  in 
the  duct.  The  duct  may  also  be  obstructed  by  a  calculus,  or  by  a 
foreign  body,  such  as  an  ascaris. 

Peritoneal  Covering-. — Stretching  of   the   peritoneal    envelope 
of  the  gland  cannot  be  blamed  for  pain  production,  for  the  very 


Area   of    tenderness 
in  pancreatic  diseasb 


Fig.  131. — Relation  of  Pancreas  to  Posterior  Abdominal  Wall. 
It  is  only  immediately  over  the  vertebrae  that  the  pancreas  comes  into 
close  relationship  with  the  wall,  the  other  portions  being  separated 
from  it  partly  by  the  duodenum  and  partly  by  the  kidneys.  Therefore 
pressure  made  between  the  second  and  third  lumbar  vertebrae  will 
cause  pain  when  the  pancreas  is  inflamed. 

good  reason  that  an  envelope  in  the  form  of  a  capsule  is  missing. 
Posterior  to  the  gland  there  is  no  peritoneum  ^   and  the  gland 

^  This  is  disputed  by  the  Viennese  schools.  It  is  quite  true,  as  stated 
by  them,  that  in  the  embryonic  development  the  gland  is  covered  by  perito- 
neum, but  English  and  American  anatomists  claim  that  during  development 
this  covering  is  absorbed  and  that  the  gland  finally  lies  in  direct  contact  with 
the  oosterior  abdominal  wall. 


584  THE   PANCREAS 

parenchyma  comes  into  direct  contact  with  the  connective  tissue 
on  the  posterior  abdominal  wall,' so  that  inflammation  of  the 
gland  itself  quickly  spreads  to  the  posterior  wall  and  causes  a 
local  pain  in  that  region.  This  pain  is  most  prominent,  though 
it  is  more  of  an  aching  than  a  pain,  and,  as  is  usual  where  the 
deeper  structures  of  any  part  are  affected,  tenderness  on  deep 
pressure  over  the  area  of  the  gland  is  present. 

Relationship  to  the  Other  Parts. — The  pancreas  lies  in  inti- 
mate relationship  with  many  important  structures.  It  is  almost 
entirely  surrounded  by  the  duodenum ;  on  either  side,  it  is  in 
contact  with  a  kidney,  while  above  it  lies  the  stomach.  The 
common  bile  duct  passes  through  its  parenchyma,  and  beneath 
its  lower  margin  pass  the  superior  mesenteric  vessels  and  nerves. 
Consequently  any  lesion,  even  the  simplest,  will  cause  a  reaction 
out  of  all  proportion  to  its  extent,  so  that  in  the  diagnosis  of  dis- 
eases of  the  pancreas  our  surveys  must  never  be  warped  by  the 
signs  due  to  associated  lesions  in  other  organs. 

One  of  the  most  confusing,  while  perhaps  the  most  important, 
of  these  symptoms  is  pain.  Pain  is  almost  always  present  in  all 
diseases  of  the  pancreas,  though  it  may  not  be  found  until  late 
in  the  process;  and  while  it  is  almost  invariably  present,  it  like- 
wise is  almost  constantly  modified  by  the  lesions  produced  in 
adjacent  organs.  The  most  commonly  associated  pain  is  that  due 
to  stenosis,  or  obstruction  of  either  the  pylorus,  the  duodenum, 
or  the  common  bile  duct.  If  gall-duct  obstruction  is  present,  colic 
occurs,  so  that  in  every  case  of  gall-diict  colic  it  must  ever  be  re- 
membered that  since  tliis  colic  is  often  due  to  the -obstruction  of 
the  common  duct  from  the  ju'essure  of  the  enlarged  head  of  the 
pancreas,  jiancreatic  lesions  should  always  be  suspected.  Pyloric 
and  duodenal  spasm  are  likewise  caused  by  obstruction  due 
to  the  same  cause.  In  all  cases  the  obstructive  symptoms  are  a 
late  manifestation  of  the  pancreatic  disease. 

Closely  related  to  the  pancreas  are  the  large  ganglia  of  the 
sympathetic.  Pressure  upon  these  ganglia  causes  a  disturbance 
which  is  reflected  as  pain  through  the  medullated  nerves  supply- 
ing the  body  wall.     Pressure  upon  the  superior  mesenteric  vessels 


GENERAL    CONSIDERATIONS  585 

and  nerves  will  produce  lesions  referable  to  the  small  intestine. 
Should  inflammation  be  communicated  to  other  organs  we  have 
the  sigTis  and  sympt07ns  of  inflammatory  trouble  in  these  organs 
in  addition  to  the  symptoms  due  to  the  pancreatic  lesion.  Not 
only  at  the  time  of  its  activity,  but  for  long  years  afterward,  in- 
flammation manifests  its  presence  by  the  pain  and  distress  due 
to  the  drag  and  jduII  from  adhesive  formations  which  it  has  left 
as  its  heritage.  Should  the  bowel  be  at  fault  the  pain  is  very 
often  relieved  when  belching  of  gas  occurs. 

Character  of  Pain. — Sudden  acute  pain  in  the  epigastrium, 
accompanied  by  shock,  should,  in  the  absence  of  lesions  indicative 
of  disease  in  other  abdominal  organs,  focus  our  attention  on  the 
pancreas.  All  of  its  acute  diseases,  such  as  inflammation  and 
hemorrhage,  cause  pain  of  a  most  agonizing  type  accompanied  by 
tenderness  on  pressure.  Should  the  pain  be  due  to  hemorrhage 
it  is  of  an  intermittent  character,  commencing  with  gTeat  severity 
and  gradually  disappearing,  to  reappear  on  the  renewal  of  the 
hemorrhage.  In  chronic  pancreatitis,  even  though  an  abscess  has 
formed,  there  is  usually  an  absence  of  pain.  However,  this  is  not 
always  the  case,  for  the  pain  may  be  severe  and  paroxysmal,  and 
the  tenderness  in  the  epigastrium  may  be  excessive.  Cysts  are 
generally  without  pain.  Calculus,  when  it  lodges  in  the  diverticu- 
lum of  Vater,  is,  as  a  rule,  most  painful,  but  it  may  exist  for 
years  in  the  body  of  the  pancreas  without  causing  pain. 

In  this  connection  Schmidt  says :  ''It  is  well  to  think  of  the 
possibility  of  pancreatic  lesions  in  all  cases  of  apparent  perito- 
nitis, or  intestinal  obstruction.  The  same  holds  true  of  all  cases 
of  colicky  abdominal  pains  which  follow  a  trauma,  blows  in  the 
epigastrium,  etc.  If  in  these  conditions  no  indication  is  found  in 
the  urine,  but  glycosuria  appears  spasmodically  or  constantly  after 
the  attack  of  pain,  the  suspicion  of  a  pancreatic  lesion  becomes 
strong.  The  opinion  is  much  strengthened  if,  in  addition  to  these 
signs,  the  stools  show  an  insufiicient  digestion  of  albumins  and 
fats,  and  physical  examination  justifies  the  consideration  of  pan- 
creatic disease." 

Location  of  the  Pain.  — Pancreatic  pain,  when  present,  is  gen- 


586  THE   PANCREAS 

erally  in  the  left  epigastrium,  and  radiates  to  the  left  inguinal 
region,  or  to  the  back  under  the  left  scapula.  This  is  a  distin- 
guishing feature  from  gall-bladder  disease,  which  generally  causes 
a  pain  under  the  right  scapula.  Should  the  pain  be  present  in 
the  epigastrium  and  radiate  around  to  both  sides  of  the  thorax, 
it  generally  indicates  a  calculus  disorder.  If  the  celiac 
plexus  be  involved  (malignant  grow^ths,  inflammatory  swelling, 
etc.),  the  pain  radiates  to  the  cardiac  region  and  resembles  angina 
pectoris. 

Chauffard  claims  that  the  initial  pain  in  the  left  epigastric 
region,  which  is  common  in  pancreatic  disease,  is  most  probably 
due  to  a  neuralgia  along  the  splanchnic  nerves  and  their  anasto- 
moses. As  the  solar  region  becomes  involved  the  pain  takes  on 
its  typical  localization  and  its  deep  agonizing  character.  The 
head  of  the  pancreas  is  closely  associated  with  the  biliary  ap- 
paratus and  if  diseased  may  in^'olve  the  common  duct  and  so  cause 
pain  referred  to  the  biliary  areas,  while  disease  of  the  body  is 
referred  principally  through  the  distribution  areas  of  the  nerves 
associated  with  the  splanchnics. 

Tenderness. — Tenderness  in  pancreatic  lesions  is  present  in 
the  epigastrium,  and  is  most  pronounced  on  deep  pressure.  This 
pain  on  pressure  may  represent  either  the  peripheral  local  tender- 
ness, as  found  in  the  zones  of  Head,  or,  if  present  only  on  deep 
pressure,  may  be  indicative  of  the  irritation  which  has  occurred  in 
the  retropancreatic  tissues.  These  structures  are  supplied  by 
spinal  nerves,  so  that  at  least  a  portion  of  the  pain  found  on  deep 
pressure  is  due  directly  to  the  pressure  exerted  by  the  examining 
hand  upon  the  hypersensitive  sensory  terminations  of  the  spinal 
nerves.  The  other  part  of  the  pain  is  due  to  reflex  tenderness 
in  the  skin  and  subjacent  tissues,  the  nerve  distribution  of  which 
is  derived  from  the  same  cord  zone  as  is  the  nerve  distribution  of 
the  pancreas. 

Because  of  the  absence  of  peritoneum  on  the  posterior  surface 
of  the  pancreas,  and  of  the  intimate  relationship  which  it  has  to 
the  postabdominal  wall,  pressure  made  to  either  side  of  the  second 
or  third  lumbar  vertebrae  is  also  provocative  of  considerable  pain. 


DISEASES    OF    PANCREAS    CAUSING    PAIN  587 

In  diabetes,  which  has  as  one  of  its  chief  pathological  phe- 
nomena a  change  in  the  islands  of  Langerhans,  there  is  often 
present,  as  pointed  out  bj  Beal,  tenderness  on  deep  percussion  or 
on  pressure  over  the  head  of  the  pancreas  or  the  descending  colon. 

Position  of  the  Patient. — The  pain  in  diseases  of  the  pancreas 
is  most  severe  in  the  continued  dorsal  position;  therefore  it  is 
■worse  at  night.  In  cysts  and  neoplasms,  the  dorsal  position,  in 
particular,  is  very  painful ;  but  on  turning  to  either  side  the  pain 
is  relieved. 


DISEASES  OF  PANCREAS  CAUSING  PAIN 

The  diseases  of  the  pancreas  producing  pain  are:  (1)  pan- 
creatitis, acute  and  chronic;  (2)  calculus  disease  of  the  pancreas; 
(3)  cystic  disease;  and  (4)  malignant  disease. 

Pancreatitis. — Acute  pancreatitis  is  o.  two  types:  hemor- 
rhagic and  inflammatory.  The  acute  variety,  especially  when  it 
is  hemorrhagic,  is  one  of  the  disasters  of  medicine.  Coming  on 
with  great  suddenness  and  with  no  appreciable  warning,  with  its 
most  severe  and  agonizing  pain  and  the  associated  symptoms  of 
collapse,  it  seems  to  be  a  prognosticator  of  the  nearness  of  death. 
In  its  onset  the  pain  may  be  so  violent  that  even  morphin  injec- 
tions will  not  relieve  it.  However,  it  gradually  becomes  less 
severe,  but  does  not  entirely  pass  away  and  has  a  tendency  to 
become  joaroxysmal  and  to  be  increased  by  movement.  This  first 
pain,  caused  by  the  violence  done  to  the  peritoneal  tissue,  is 
accentuated  later,  probably,  by  beginning  sepsis,  fat  necrosis,  or 
other  effects  of  the  pancreatic  disorder.  The  pain  may  be  re- 
ferred to  the  epigastrium  or,  in  some  cases,  to  the  entire  anterior 
abdominal  wall.  In  other- instances  it  may  be  referred  to  the 
lower  abdomen  to  such  an  extent  that  a  low  abdominal  incision 
has  been  made  under  the  mistaken  impression  that  the  lesion  was 
in  the  pelvis  (Deaver). 

Tenderness  is  present  above  the  umbilicus,  generally  to  the 
right  of  the  median  line.  In  many  cases  it  is  very  slight,  though 
generally  on  a  careful  examination  it  is  elicited.     "It  becomes 


588  THE   PANCREAS 

more  marked  if  the  case  progresses  to  suppuration,  especially  with 
the  formation  of  a  mass  which  is  practically  always  tender" 
(M.  F.  Kichardson). 

Fitz's  Rule. — In  relation  to  acute  pancreatitis  Fitz  has 
formulated  the  following  rule,  namely,  that  acute  pancreatitis  is 
to  be  suspected  when  a  previously  healthy  person,  or  sufferer  from 
occasional  attacks  of  indigestion,  is  suddenly  seized  with  violent 
pain  in  the  epigastrium,  followed  by  vomiting  and  collapse,  and 
in  the  course  of  twenty-four  hours  by  a  circumscribed  epigastric 
swelling,  tympanitic  or  resistant,  with  slight  rise  of  temperature. 
Fat  necrosis,  likewise,  is  generally  present. 

Symptoms  of  acute  pancreatitis  associated  with  the  pain  are: 
(a)  vomiting,  which  is  almost  an  invariable  accompaniment,  the 
vomitus  at  first  consisting  of  food  and  then  of  blood ;  (b)  belch- 
ing of  gas;  and  (c)  hiccoughs,  persistent  and  uncontrollable. 
Acute  pancreatitis  is  frequently  confused  with  intestinal  obstruc- 
tion, but  the  shock,  slow  pulse,  and  cyanosis  present  in  acute  pan- 
creatitis are  rather  characteristic.  In  intestinal  obstruction  the 
pain  may  be  localized  in  any  part  of  the  abdomen,  while  in  acute 
pancreatitis  it  is  localized  in  the  epigastrium.  Jaundice,  the  rapid 
production  of  free  fluid  in  the  peritoneal  cavity,  absence  of  fecal 
vomit,  and  the  development  of  a  tumor  in  the  epigastrium  are 
confirmative  of  pancreatitis  and  negatory  for  intestinal  obstruc- 
tion. 

Subacute  Pancreatitis. — The  course  of  a  pancreatitis  of  a 
mild  type  is  variable.  It  generally  begins  with  a  slight  pain  in 
the  epigastrium,  coming  on  a  few  hours  after  meals.  The  pain 
gradually  becomes  worse  until  it  resembles  biliary  colic.  After  an 
acute  attack  of  pain  there  is  a  period  of  freedom ;  then,  suddenly, 
the  patient  again  has  a  most  severe  paroxysm.  Gradually,  the 
pain  becomes  less  intermittent  and  more  continuous.  All  these 
pains  are  most  pronounced  in  the  epigastrium,  but  may  radiate 
to  the  back,  between  the  shoulders,  to  the  region  of  the  appendix, 
to  the  legs,  or  to  the  lumbar  region.  In  some  cases  the  epigastric 
pain  may  be  lacking,  while  the  referred  pain  is  present. 

Tenderness  is  variable.    It  is  found  in  the  epigastrium,  either 


PANCREATIC   DIFFERENTIAL  DIAGNOSIS' 


Pancreatitis 

Intestinal  Odstructioxs 

Biliary  Colic 

Cholecystitis 

Acote  Generalized  Peritonitis 

Pain. 

Sudden,  severe,  paroxysmal.     Begins 
and   continues  in    the   epigastrium 
with  more  or  less  of  a  tendency  to  be 
felt  to  the  left  of  than  in  the  median 
line.     Pain  is  also  felt  between  the 
shoulders. 

Sudden,  continuous,  of  grad- 
ually increasing  intensity,  with 
a  possible  extension  over  the 
entire   abdomen,   due   to   the 
development  of  a  general  peri- 
tonitis. 

Sudden,  paroxysmal, 
has    a  tendency    to 
radiate    to    right 
shoulder    and   scap- 
ula.    See  under  Bil- 
iary CoHc. 

Slow  and  gradual  in 
onset;  duct  and  gall 
bladder  areas  invol- 
ved. Tenderness 
marked  over  the  gall 
bladder. 

Sudden  pain,  generally  following 
a  perforation.  The  pain  at 
first  is,  as  a  rule,  in  the  center 
of  the  abdomen  in  the  umbilical 
region,  then  becomes  diffused  as 
the  peritonitis  spreads. 

Jaundice. 

Present. 

Absent. 

Generally  present. 

Generally  absent. 

Absent. 

Pulse. 

Slow,  except  when   shock  is  associ- 
ated ;  then  it  is  rapid  and  thready. 

Gradually    increasing  in 
rapidity. 

Variable,  but  gener- 
ally slow. 

Gradually  increasing 
in  rapidity. 

Gradually  increasing  in  rapidity, 
it  finally  becomes  thready. 

Tumor. 

A   gradual    development   of   one   In 
the  epigastrium. 

Present,  tympanitic  over  the 
region  of  the  obstruction. 
Rare  in  the  epigastrium. 
Not  tender  on  pressure. 

Absent;      at    times 
may  be  present  due 
to  a  distended  gall 
bladder. 

Present  over  area  of 
gall  bladder.  Is  very 
tender  on  pressure. 

Absent. 

Vomiting. 

Present,  generally  persistent.     Bile 
generally     present,     gradually     be- 
comes less  frequent. 

Vomiting,  at  first  of  stomach 
contents,  then  of  bile  and  then 
of  fecal  contents. 

Generally  present. 
No  bUe. 

(ienerallv  present. 
Bile. 

Generally  present  and  persist- 
ent.    Bile  is  frequently  present. 

Temperature. 

Present  with  chills. 

Absent  at  first. 

Absent. 

(1  en e rally  present 
with  occasional  chills. 

Generally  jiresent. 

Distention. 

Largely  colonic,  generally  the  tym- 
pany is  marked,  especially  in 
epigastrium. 

May  occur  in  any  part  of  the 
bowel;  always  above  the  area 
of  obstruction. 

Absent. 

Absent. 

Generally  present  and  is  most 
marked  over  the  entire  abdo- 

Free  fluid  in  peri- 
toneal cavity. 

Rapid  development  of. 

Little  if  any  free  fluid. 

Absent. 

.Vbsent. 

Present  but  difficult  to  define. 

Shock. 

Present. 

Absent.                                              .Absent. 

Absent. 

Absent. 

Diarrhea. 

Present;  excess  of  fat  in  stools. 

Obstipation. 

Constipation;  no 
bile  salts  in  stool. 

Stools  may  be  nor- 
mal. 

Constipation. 

Hiccough. 

Present. 

Generally  absent. 

Absent. 

May  be  present. 

Mav  be  present;  generallv  ab- 
sent. 

Belching. 

Present. 

May  be  present. 

Absent. 

Generally  absent. 

May  be  present. 

High  enemata. 

Generally  result  in  the  passage  of 
gas  and  fecal  matter,  and  the  reduc- 
tion of  the  distention. 

Result  in  ilir  p:,<s;ice  of  some 
f<'c:il  iii.iiiir,  :in.l  ilic  cleansing 
of  lli.|:u-rl),,u(l,liut  withno 
IcsHi'iiint;  vi  l.hc  distention. 

No  effect. 

No  effect. 

No  effect. 

Urine. 

Glycosuria  intermittently  present. 

No  bile  nor  sugar. 

Bile  present  in  colic 
of  common  duct. 

Not  much  change. 

Indican  may  be  present. 

•Pancreatic  lesions  should  also  be  diagnosed  from  atheroma  of  the  aorta,  where  the  pain  is  purely  epigastr 


DISEASES    OF    PANCREAS    CAUSING   PAIN  589 

to  the  right  or  to  the  left  of  the  median  line,  depending  upon  the 
part  of  the  pancreas  which  is  involved  in  the  inflammatory  proc- 
ess. Pns  when  it  forms  generally  gravitates  toward  the  back. 
Then  the  most  severe  pain  is  felt  in  the  groin. 

Associated  symptoms  of  subacute  pancreatitis  are:  (1)  col- 
lapse; (2)  frequent  and  small  pulse;  (3)  temperature  but  little 
raised;  (4)  face  of  grayish  pallor,  with  signs  of  anxiety;  (5) 
mind  clear,  with  little  delirium;  (6)  tongue  dry;  (7)  retching 
and  vomiting,  the  vomitus  frequently  containing  bile,  seldom  fecal 
matter  or  blood;  (8)  tumor  mass  present  in  the  upper  abdomen; 
(9)  peritonitis  beginning  and  spreading  downward,  but  with  no 
decided  resistance  to  the  abdominal  wall;  (10)  emaciation  and  as- 
thenia developing  and  progressing  till  death  ensues. 

Chronic  Pancreatitis. — Either  acute  or  subacute  pancreatitis 
may  persist  and  become  chronic.  Here  the  epigastric  pain  may 
be  severe  or  very  mild.  It  may  be  continuous  or  paroxysmal.  In 
some  cases  it  resembles  a  gall-bladder  colic,  except  that  the  pain 
is  not  over  the  gall-bladder  region.  It  is  more  to  the  center  of 
the  epigastrium  and  has  a  tendency  to  radiate  to  the  left  side, 
while  the  pain  in  gall-bladder  colics  has  a  tendency  to  radiate  to 
the  right  side.  Chronic  pancreatitis  is  also  associated  with  jaun- 
dice, which  gi-adually  becomes  more  severe ;  it  also  causes  weak- 
ness, debility,  emaciation,  the  presence  of  a  tumor  mass  in  the 
epigastrium,  and  frequent  diarrhea.  Cases  of  chronic  pancreati- 
tis have  been  reported  in  which  pain  was  felt  in  the  left  iliac 
region  or  under  the  ninth  or  tenth  costal  cartilage  on  the  left 
side. 

Pancreatic  Calculi. — Pancreatic  calculi  cause  a  colic  some- 
what similar  to  the  colic  due  to  gall  stones,  with  the  exception 
that  in  gall-stone  colic,  pain  is  referred  to  the  right  shoulder  aiid 
is  present  in  the  right  side  of  the  epigastrium,  while  the  colic  of 
pancreatic  calculi  is  generally  in  the  left  side  of  the  epigastrium 
and  radiates  to  the  left  shoulder.  It  is  also  noticeably  different 
from  gall-stone  colic  in  the  infrequency  with  which  jaundice  is 
associated  with  it.     Reasoning  from  the  probability  of  chance, 


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DISEASES    OF   PANCREAS    CAUSING   PAIN  591 

pain  of  a  typical  duct-colic  type  is  more  likely  to  be  due  to  ob- 
struction of  the  gall  ducts  than  to  obstruction  of  the  pan- 
creatic ducts,  for  gall  stones  are  four  or  five  times  as 
common  as  pancreatic  stones.  In  some  cases  of  pancreatic 
calculi  pain  may  be  absent,  with  only  a  soreness  in  the 
epigastrium,  or  an  aching  in  the  upper  lumbar  region.  When  at 
its  height  the  pain  may  be  associated  with  hiccoughs,  vomiting, 
rigors,  cold  sweats,  and  collapse.  In  one  case  in  which  pain  was 
j)resent  in  the  left  iliac  fossa  considerable  free  fluid  was  found  in 
this  fossa.  In  another  case  pain  was  present  after  the  first  six  or 
eight  hours  only  in  the  region  of  the  ninth  and  tenth  costal  carti- 
lages on  the  left  side. 

Cystic  Disease  of  the  Pancreas. — The  distress  in  cystic  disease 
of  the  pancreas  may  vary  from  a  feeling  of  uneasiness  and  dis- 
comfort in  the  epigastric  region  to  one  of  the  most  severe  pain. 
It  also  may  bo  broken  by  acute  exacerbations,  probably  due  to 
the  sudden  increase  of  tension  in  the  cyst  walls,  which,  in  turn, 
is  caused  by  a  sudden  increase  (frequently  due  to  hemorrhage) 
in  the  volume  of  the  cyst  contents.  Like  other  varieties  of  pan- 
creatic pain  it  is  generally  confined  to  the  upper  abdomen,  but 
may  radiate  to  the  back  and  has  been  known  to  strike  down  into 
the  testicles. 

Cancer  of  the  Pancreas. — The  pain  of  cancer  of  the  pancreas 
is  the  result  of  pressure  on  the  neighboring  structures  or  on  the 
pancreatic  tissues.  It  may  be  very  mild  or  very  severe,  continu- 
ous or  intermittent.  It  frequently  starts  under  the  costal  cartilage 
of  the  left  side  and  gTadually  extends  toward  the  midline,  low  in 
the  epigastrium,  radiating  around  one  or  both  sides  to  the  shoul- 
der or  to  the  back  (generally  to  the  left  side).  It  is  worse  at 
night ;  paroxysms  are  frequent  and  give  a  corset-like  constriction. 
Because  of  its  pressure  on  the  gall  duct,  over-distention  of  the 
gall  bladder  occurs,  producing  a  most  severe  gall-bladder  colic. 
Pressure  on  the  pylorus  may  be  the  inciter  of  a  pyloric  or  gastric 
spasm.  Curtin  speaks  of  a  case  of  cancer  -of  the  pancreas  in 
which  the  pain  radiated  to  the  inguinal  canal,  back  of  the  testicles 


592  THE    PANCREAS 

and  perineum,  and  down  the  thighs  as  far  as  the  knees.  In  his 
case  the  most  prominent  symptom  was  a  girdle  sensation  about 
the  level  of  the  tenth  costal  interspace.  In  cancer  of  the  pancreas 
the  patients  generally  assume  a  posture  in  which  the  body  is 
bent  forward  and  the  knees  drawn  up. 


CHAPTEE  XXVIII 


THE  SPLEEN 


GENERAL     CONSIDERATIONS 

Anatomy. — The  spleen  is  the  largest  ductless  gland  in  the 
body.  It  is  situated  in  the  left  hypochondrium  and  is  in 
intimate  anatomical  relation  to  the  digestive  apparatus.  There- 
fore, it  is  particularly  prone  to  enlargement  in  diseases 
of  the  liver,  stomach  and  intestines.  Any  acute  enlargement  is 
painful. 

A  small  part  of  the  superior  surface  of  the  spleen  is  in  inti- 
mate contact  with  the  diaphragm  in  the  vicinity  of  the  esophageal 
opening.  The  contact  is  very  firm  and  so  close  that  any  disturb- 
ance in  the  spleen  would  cause  some  related  change  in  this  part 
of  the  diaphragm,  so  that  disorders  of  the  spleen  may  exert  trac- 
tion on  this  section  of  the  diaphragm  and  so  cause  irritation  to 
the  peripheral  branches  of  some  of  the  intercostal  nerves  distrib- 
uted on  its  lower  surface,  with  consequent  pain,  which  is  referred 
to  the  body  Avail. 

Nerve  Supply. — The  spleen  receives  its  nerve  supply  from 
the  sympathetic.  The  fibers  accompany  the  blood  vessels  to  the 
ultimate  divisions  and  supply  the  parenchyma  of  the  gland.  They 
are  derived  from  the  splenic  plexus,  a  division  of  the  celiac 
plexus.  From  the  celiac  plexus  collateral  branches  connect  with 
the  right  vagus,  which,  in  turn,  is  in  communication  with  the  right 
spinal  accessory  and  the  cervical  plexus.  Thus  we  may  account 
for  the  shoulder  pain  on  the  right  side. 

Embleton  believes  that  "the  splenic  nerves  are  derived  from 
each  side  of  the  semi-lunar  ganglion  and  from  each  of  the  mem- 
bers of  the  par  vagum,  and  thus,  by  receiving  nerve  twigs  from 

593 


594  THE   SPLEEN 

each  pneumogastric,  the  shoulder  jDaiii  of  the  right  side  may  be 
accounted  for."  This  is  probably  not  true.  (See  Bechterew, 
"Funktionen  der  ISTervencentra,"   I,  p.   376.) 

According  to  Lyon,  "The  spleen  is  supplied  by  nerve  fibers 
from  the  left  splanchnic  nerve,  through  which  a  control  of  the 
size  of  the  organ  is  obtained.  Stimulation  of  the  splanchnics 
causes  contraction  of  the  organ,  whereas  cutting  them  causes 
splenic  enlargement." 

The  splanchnics  carry  both  sensory  and  motor  stimuli.  Pain 
in  splenic  disorder  may  therefore  also  be  due  largely  to  irritation 
of  their  terminal  branches  from  increase  in  tension  of  the  splenic 
capsule. 

Character  of  the  Pain. — Many  of  the  lesions  of  the  spleen 
progress  entirely  without  pain,  though  in  nearly  all  cases,  even 
when  pain  is  absent,  there  is  present  a  feeling  of  dragging  or  of 
pulling  in  the  left  hypochondrium.  Sometimes  there  is  also  a 
feeling  as  of  weight  in  the  epigastrium,  or  a  sense  of  tension  in 
the  splMiic  area.  These  pains  and  discomforts  generally  extend 
from  the  left  side  around  into  the  epigastrium.  They  may  be 
spontaneous,  but  most  frequently  are  felt  only  on  mechanical  irri- 
tation, such  as  comes  from  running,  jumping,  or  from  trauma  on 
the  left  side. 

In  splenitis  and  ^perisplenitis  the  pain  is  generally  worse  about 
four  hours  after  eating,  because  at  this  period  digestion  is 
at  its  height,  and  the  blood  supply  to  the  spleen  is  at  its  maximum. 
Consequently  it  is  at  this  time  that  the  spleen  has  reached  its 
greatest  size,  the  tension  on  the  capsule  is  greatest,  and  the  pain  is 
most  severe.  From  then  on  the  pain  gradually  decreases  until 
about  the  twelfth  hour,  when  it  ceases,  for  the  spleen  has  returned 
to  its  normal  size.  The  reason  for  this  splenic  enlargement  is 
that  the  spleen  is  supposed  to  act  as  a  resen'oir  for  portal  blood, 
which,  during  the  active  stage  of  digestion,  is  gi^eatly  increased 
in  quantity,  with  a  consequent  increase  in  the  quantity  present  in 
the  spleen.  This  increase  in  size  is  the  result  of  a  vasomotor  dila- 
tation of  the  blood  vessels  of  the  spleen,  with  a  general  relaxation 
of  the  musculature  of  the  orgaxu 


GENERAL   CONSIDERATIONS 


595 


A  very  significant  feature  in  splenitis  is  tenderness  of  the  left 
pneumogastrie. 

Of  ten  cases  of  splenitis  (Embleton),  in  six  cases  the  left 
pneumogastrie  was  found  tender  on  pressure^  while  in  two  cases 
this  condition  was  found  in  the  right  pneumogastrie. 


Localized  point  of  ten- 
derness 


Signorelli's  spleen  point 


Fig.  133. — Points  of  Pain  and  Tenderness  in  Diseases  of  the  Spleen. 
Pain  present  in  epigastrium,  upper  part  along  the  costal  margin. 


Localized  point  of  ten- 
derness 


Fig.  134. — Points  of  Pain  and  Tenderness  in  Diseases  of  the  Spleen. 
Pain  in  interspaces,  especially  those  lying  directly  over  the  spleen. 


596 


THE    SPLEEN 


Position  of  Patient. — A  patient  suffering  from  splenitis  gen- 
erally finds  the  dorsal  position  and  tlie  left-sided  position 
painful. 

Tenderness. — Localized  points  of  tenderness  are  found  in  the 
shoulder  over  the  acromion  process,  and  at  the  "junction  of  the 
upper  and  middle  third  of  the  upper  edge  of  the  trapezius 
muscle."     SigTiorelli's  spleen  point  is  near  the  intersection  of  the 


Fig.  135. — Method  of  Palpating  for  Splenic  Tenderness. 
The  patient  is  placed  in  a  reclining  posture  with  the  knees  flexed  on  the 
thighs,  and  the  thighs  on  the  abdomen;  the  abdominal  muscles  are 
also  relaxed.  The  examiner  stands  to  the  right  of  the  patient  and 
introduces  his  right  hand  deep  under  the  left  costal  border  and  the 
left  hand  makes  pressure  over  the  left  hypochondrium.  The  patient 
now  takes  a  deep  breath  and  if  the  spleen  is  tender,  pain  is  complained 
of  when  it  comes  in  contact  with  the  examiner's  hand.  In  case  of 
enlargement  the  deep  inspiration  may  not  be  necessary. 

left  fifth  intercostal  space  and  the  mid-clavicular  line.  Tender- 
ness is  also  felt,  both  on  palpation  and  percussion  over  the  splenic 
area. 

Factors  Influencing  Pain. — Factors  influencing  the  onset  of 
pain  are  motion,  pressure,  and  circulation.  Motion  is  a  cause  of 
pain,  especially  should  the  movement  be  in  the  form  of  quick, 
sharp  jerks  or  jars,  such  as  occur  in  running,  jumping,  and  horse- 
back riding.  Change  of  position  of  the  organ,  such  as  happens 
in  turning  the  body  from  the  dorsal  to  the  left-lateral  position, 


GENERAL    CONSIDERATIONS 


597 


causes  a  sense  of  tension  or  of  pain  in  the  left  side.     Tkis  is  most 
prominent  when  the  stomach  is  full. 

Diaphragmatic  movements,  such  as  occur  in  sneezing,  cough- 
ing and  hiccoughing,  also  cause  pain.  Pressure  on  the  organ  also 
very  frequently  produces  pain.  Such  pressure  is  exerted  by  the 
patient  himself  when  he  bends  forward  or  backward.  In  either 
case  the  spleen  is  caught  in  the  recess  of  the  diaphragm  and  is 
squeezed  considerably.  If  it  is  not  enlarged  the  force  of  the 
pressure  may  not  be  great  enough  to  cause  pain ;  but  should  it  be 
enlarged  the  least  amount  of  pressure  is  very  painful.  For  the 
same  reason,  straining  efforts,  such  as  take  place  in.  defecation 
and  in  lifting,  are  very  painful.     Pressure  may  also  be  exerted  by 


»■  A, 

^-   / 

Spleen 

1 

Kidney 

— ww> 

f- .  -I 

|:' 

fcg 

\ 

Fig.  136. — Location  of  the  Kidney.     (Campbell.) 

the  descent  of  the  diaphragm ;  thus,  deep  breathing  is  productive 
of  pain.  This  is  markedly  so  should  perisplenitis  be  present. 
Palpation,  especially  when  bimanual,  causes,  in  a  tender  spleen, 
considerable  pain.  The  method  of  palpation  is  shown  in  Fig.  135. 
Percussion  is  also  painful,  particularly  if  the  percussing  blow  is 
rather  heavy.  "Both  palpation  and  percussion  are  made  in  the 
splenic  area,  which  is  marked  out  upon  the  back,  by  drawing  two 
horizontal  lines  from  the  spinous  processes  of  the  ninth  dorsal 
and  the  first  lumbar  vertebrse;  these  are  joined  by  a  vertical  line 
one  and  one-half  inches  to  the  left  of  the  midline  of  the  body, 
and  another  corresponding  with  the  left,  midaxillary  line" 
(Monyhan).  Within  this  quadrilateral  space  the  spleen  lies 
obliquely  between  the  ninth,  tenth,  and  eleventh  ribs. 

Circulatory  changes  during  digestion  also  produce  and  modify 
spleen  pains ;  at  this  time  there  is  present  a  secondary  hyperemia 


598  THE    SPLEEN 

in  the  spleen.  If  pain  is  already  present,  it  is  increased;  or,  if 
it  is  not  present,  it  is  initiated.  Should  the  spleen  be  inflamed, 
or  adhesions  be  j^resent,  the  pain  is  all  the  more  pronounced. 
Adhesions  between  the  stomach  and  the  spleen,  or  the  spleen  and 
the  colon,  are  the  most  painful  because,  in  these  cases,  during  cer- 
tain stages  of  digestion,  enlargement  of  both  organs  occurs  and 
the  jniU  is  doubly  severe.  Drugs,  such  as  quinin  and  arsenic, 
lessen  splenic  pain,  because  of  the  decrease  in  the  size  of  the 
spleen  which  they  cause. 

Symptoms  associated  with  a  painful  or  tender  spleen  are : 
Enlargement,^  which  is  almost  invariably  present.  Very  often 
the  pain  and  tenderness  seem  to  vary  directly  with  the  size  of  the 
spleen.  In  nearly  all  cases  of  diseased  spleen  there  is  present  an 
inflammation  or  some  congestion  of  the  capsule.  This  causes  a 
deposit  of  fibrin  on  the  peritoneal  surface,  or  at  least  a  roughening, 
which  gives  rise  to  friction  when,  during  respiration  or  deep 
breathing,  a  to-and-fro  motion  occurs  between  the  spleen  and  the 
diaphrag-m.  This  friction  rub  can  be  heard  on  auscultation,  and 
be  felt  on  palpation.  Sometimes,  in  severe,  active  congestion,  a 
systolic  murmur  can  be  defined  on  listening  over  the  sj)lenic  area. 

DISORDERS    OF    THE    SPLEEN   PRODUCING   PAIN 

Displaced  or  Movable  Spleen — Gleuard  states  that  a  mov- 
able spleen  may  be  present  without  any  special  symptoms,  though 
generally  a  dragging  or  a  sense  of  pulling  in  the  back  or  sides, 
referred  along  the  line  of  attachment  of  the  diaphragm  to  the 
ribs,  is  present.  Other  organs  may  be  affected  by  the  displaced 
spleen;  their  circulation  becomes  disturbed,  congestion  results, 
and  pain  is  produced.  When  the  displacement  is  excessive  the 
splenic  pedicle  may  be  twisted  and  the  splenic  circulation  inter- 
rupted. Pain  now  becomes  a  prominent  symptom,  the  character 
and  severity  depending  upon  the  completeness  of  the  circulatory 

'  The  spleen  is  increased  in  size,  should  its  anterior  border  lie  below  the 
line  extending  from  the  middle  of  the  sternal  notch  to  the  tip  of  the  eleventh 
rib  on  the  left  side. 


DISORDERS    PRODUCING    PAIN  599 

obstruction.  Should  the  veins  alone  be  obstructed,  congestion 
results.  The  pain  is  very  severe  and  the  spleen  is  increased  in 
size.  Should  the  obstruction  be  complete,  both  arteries  and  veins 
being  blocked,  the  spleen  at  first  is  not  increased  in  size,  and  con- 
sequently pain  is  not  prominent.  In  gradual  venous  obstruction 
the  pain  is  not  as  severe  as  it  is  in  venous  obstruction  of  sudden 
onset.  In  either  case,  whether  the  obstruction  is  complete  or 
incomplete,  complicating  perisplenitis,  with  secondary,  pain,  re- 
sults. The  diagnosis  of  movable  spleen  can  be  made  from  the 
shape  of  the  tumor  mass,  which  is  oblong,  with  an  indented 
border  and  pulsating  artery  on  its  inner  surface.  The  absence 
of  the  spleen  from  its  normal  position,  and  the  ability  to  replace 
the  tumor  mass  in  the  cavity  the  spleen  should  normally  occupy 
also  assist  in  the  diagnosis. 

Displacement  of  the  spleen  is  very  rare,  Glenard  having  found 
only  two  in  one  hundred  and  sixty  cases  of  enteroptosis,  a  condi- 
tion with  which,  naturally,  one  would  suppose  it  would  be  asso- 
ciated. 

Congestion. — Congestion  of  the  spleen  causes  pain  in  nearly 
every  case.  This  is  well  illustrated  in  the  infectious  diseases, 
which  are  almost  invariably  accompanied  by  a  congested  spleen 
and  have  pain  in  the  left  hypochondrium.  The  presence  of  a 
tumor  below  the  left  costal  arch,  moving  with  respiration,  and 
tender  to  the  touch,  is  a  sine  qua  non  of  splenic  involvement.  In 
some  cases  of  acute  splenic  congestion,  accompanied  by  cardiac 
disease,  pulsation  may  be  felt.  In  these  cases  the  pain  may  be 
localized  to  the  splenic  area,  or  may  radiate  in  different  directions. 
An  acute  congestion  of  the  spleen,  originating  in  the  presence  of 
a  gastric  ulcer,  may  be  due  to  a  thrombus  of  the  splenic  vein,  the 
thrombus,  in  turn,  being  caused  by  necrotic  tissue  or  blood  clot 
arising  from  the  ulcer. 

The  spleen,  which  in  infectious  diseases  is  enlarged  and  con- 
gested, may  also  show  signs  of  acute  inflammation.  In  this  it 
does  not  differ  from  the  lymphatic  glands,  which  in  the  presence 
of  infection  become  enlarged,  and,  in  some  cases,  acutely  inflamed. 

However,  the  sjileen  especially,  because  of  idiosyncrasy  and 


600  THE   SPLEEN 

special  peculiarity  of  function,  seems  particularly  liable  to  in- 
volvement in  all  acute  infectious  processes.  Several  factors  may 
account  for  tins  tendency,  namely:  (1)  because  of  the  great 
amount  of  lymphatic  tissue  in  its  substance  it  acts  as  a  producer 
of  leukocytes,  and  at  the  same  time,  (2)  because  of  its  relation- 
sliip  to  the  circulation,  it  performs  the  fimction  of  a  filter  for  a 
portion  of  the  blood.  Thus,  infections  and  septic  conditions,  by 
casting  detritus  and  bacteria  into  the  circulation,  are  particularly 
prone  to  cause  splenic  disease.  The  infectious  diseases  causing 
the  most  marked  enlargement  are  typhoid  fever  and  malaria.  In 
both  diseases  the  spleen  is  enlarged  and  tender,  and  pain  is  com- 
plained of  beneath  the  left  costal  arch.  The  enlarged  spleen  fre- 
quently compresses  that  jDortion  of  the  lung  between  the  dia- 
phragm and  the  thoracic  wall  so  that,  on  deep  breathing,  a  fine 
crepitation  may  be  heard.  This,  at  times,  has  led  to  a  confusion 
of  the  splenic  lesion  with  pneumonia.  Such  a  mistake  is  most 
likely  to  happen  if  the  onset  of  the  disease  causing  the  spleen  in- 
volvement occurs  with  a  chill.  Deep  breathing  in  the  presence 
of  an  enlarged  and  tender  spleen  is  very  painful.  Because  of  the 
associated  splenic  congestion,  paroxysmal  hemoglobinuria  also 
causes  splenic  pain. 

In  brief,  it  may  be  said  that  the  causes  of  active  congestion 
and  inflammation  of  the  spleen  are  due:  (1)  to  acute  factors, 
as  microorganisms  and  their  toxins  (typhoid  fever,  malaria, 
syphilis),  drugs  (acetanilid  and  other  coal-tar  derivatives), 
trauma,  and  local  and  morbid  processes  in  the  spleen  (hemor- 
rhage, embolism)  ;  (2)  to  chronic  factors,  such  as  anemic  states 
(pernicious  anemia,  chlorosis,  infantile  anemia,  splenic  anemia, 
chronic  cyanotic  polycythemia,  rickets)  ;  or  (3)  to  passive  con- 
gestions, which  may  be  due  (a)  to  disease  of  the  heart  and  lungs 
(producing  obstruction  to  the  general  circulation),  (b)  to  diseases 
of  the  portal  area  (causing  obstruction  to  the  portal  circulation), 
such  as  cirrhosis  of  the  liver  and  pyelophlcbitis,  or  (c)  pressure 
on  the  portal  or  splenic  veins  by  tumors,  adhesions,  and  sometimes 
by  an  enlarged  and  inflamed  gall  bladder  (Lyon). 

Perisplenitis. — In  perisplenitis  pain  is  almost  invariably  pres- 


DISORDERS    PRODUCING    PAIN  601 

ent,  especially  if  the  inflammatory  process  is  acute.  The  pain 
varies  from  a  feeling  of  discomfort  to  one  of  the  greatest  distress. 
All  movements  of  the  spleen  initiate  and  aggravate  it,  particu- 
larly those  movements  associated  with  breathing,  turning  or  twist- 
ing of  the  body,  and  bending  forward  or  backward. 

Of  diagnostic  importance,  if  the  lesion  is  acute,  are  the  fric- 
tion sounds,  which  may  be  heard  over  the  splenic  area  on  auscul- 
tation. Great  tenderness,  also,  is  present  on  pressure  over  the 
same  area.  In  cirrhosis  of  the  liver  perisplenitis  frequently 
occurs.  It  is  found  in  syphilitic,  Banti's  and  Hanot's  cirrhoses, 
while  Laennec's  cirrhosis  rarely  causes  pain. 

The  causes  of  perisplenitis,  according  to  Lyon,  are:  (1)  local- 
ized splenic  involvement,  as  infarct,  gumma,  hemorrhage,  abscess, 
cysts;  (2)  generalized  involvement  of  the  splenic  parenchyma  in 
the  acute  or  chronic  splenitis  of  the  infectious  diseases;  and  (3) 
extension  of  inflammation  from  disease  outside  of  the  spleen,  as 
pleurisy,  pneumonia,  local  or  general  peritonitis,  tumors  or  cysts. 

Abscess  of  the  Spleen. — Abscess  is  most  frequently  caused  by 
lodgment  of  a  septic  embolus ;  but  so  long  as  the  abscess  is  con- 
fined to  the  parenchyma  it  gives  no  indication  of  its  presence. 
It  is  only  when  the  capsule  is  involved,  and  perisplenitis  occurs, 
that  pain  is  felt.  The  pain  of  central  abscess  and  other  crypto- 
genic forms  of  splenic  involvement  miglit  be  of  great  diagnostic 
value ;  but,  unfortunately,  as  yet  the  pain  equivalent  has  not  been 
defined  and  correlated  to  the  different  varieties  of  splenic  disease. 

Infarct. — In  infarct  of  the  spleen  sudden,  severe  pain  is  felt 
in  the  splenic  area.  Tenderness  due  to  perisplenitis  is  also  pres- 
ent and  is  localized  over  the  area  of  the  infarct.  After  the  first 
acute  pain,  following  the  lodgment  of  the  embolus,  the  pain 
syndrome  is  that  of  a  perisplenitis.  The  emboli  causing  these 
infarcts  are  most  commonly  due  to  vegetative  endocarditis,  in 
which  a  portion  of  these  vegetations  has  been  carried  away  in  the 
blood  current  and  has  lodged  in  the  splenic  artery  or  its  branches. 
Such  a  lodgment  is  very  common,  because  in  the  spleen  the  ar- 
teries are  end-arteries  and  have  no  anastomoses ;  therefore,  lodg- 


602  THE    SPLEEN 

ment  always  cuts  off  the  circniation  to  a  limited  area  and  causes 
an  infarct.  Should  the  embolus  be  septic  an  abscess  of  the  spleen 
results. 

Rupture  of  the  Spleen. — Pain  in  the  splenic  area,  following  a 
blow  or  a  sudden  trauma  in  the  region  of  the  spleen,  particularly 
if  it  be  associated  with  collapse  and  signs  of  internal  hemor- 
rhage, is  an  indication  of  sjDlenic  rupture.  The  patient,  in  addi- 
tion to  the  pain,  has,  at  the  time  of  the  accident,  a  sensation 
as  of  something  being  torn  or  of  giving  way  in  the  abdomen. 
However,  pain  does  not  at  once,  in  all  cases,  occur,  for  immedi- 
ately after  the  injury  the  patient  may  seem  but  little  hurt.  He 
may  be  able  to  walk  for  some  distance  or  to  engage  in  some  work 
before  the  pain  comes  on.  A  rupture  may  also  occur  sponta- 
neously, as  has  been  observed  in  a  few  cases  of  very  large  and 
congested  spleens. 

Tumors  of  the  Spleen. — Tumors  of  the  spleen,  according  to 
Monyhan,  are,  as  a  rule,  painful,  the  pain  in  some  cases  being  so 
severe  as  to  prevent  the  slightest  movement.  On  the  other  hand, 
the  enlarged,  amyloid  spleen,  found  in  septic  diseases,  is  apt  to 
be  overlooked,  because  it  rarely  produces  a  pain-complex. 

Cysts  of  the  Spleen.  - — Likewise,  cysts  of  the  spleen,  unless  of 
very  great  size,  are  generally  free  from  pain,  though  from  their 
size  they  may  cause  a  sensation  of  weight  or  of  fulness  in  the  epi- 
gastrium. Pain,  when  present,  is  in  the  area  occupied  by  the 
enlarged  spleen.  Hydatids,  as  a  rule,  are  painless.  They  usually 
grow  from  the  upper  surface  of  the  gland  and  give  a  character- 
istic thrill  on  palpation. 

Kala-azar,  a  rare  disease  of  the  spleen  found  in  certain 
tropical  countries,  produces  a  splenic  enlargement,  which,  as  a 
rule,  is  painless. 

Of  the  blood  diseases  causing  splenic  enlargement,  myeloge- 
nous leukemia  always  causes  pain.  This  pain,  due  to  distention 
of  the  capsule,  is  frequently  the  first  symptom  of  the  disease. 
Pseudoleukemia  and  polycythemia  also  cause  splenic  pain,  but 
this  is  rare  in  chlorosis  and  pernicious  anemia.     The  reason  for 


DIFFERENTIAL    DIAGNOSIS 


603 


this  may  be  that  the  spleen  is  enlarged  in  only  about  sixteen  per 
cent,  of  cases  of  pernicious  anemia  and  chlorosis  (Schmidt).  It 
is  only  in  the  cases  of  enlarged  spleen  that  pain  is  present. 

SPLEEN.     DIFFERENTIAL   DIAGNOSIS.' 


Symptoms 

Spleen 

Pleurisy 

Pneumonia 

Pain. 

Felt  in  right  side  or 
is  referred  to  the  ab- 
domen.      Worse  on 
respiration. 

Localized  to 
diseased  area; 
not  such  a  great 
tendency    to    be 
referred. 

Localized  over 
area  \<'hen  pleura 
is  involved.  Re- 
ferred pain  over 
the  chest  wall  is 
also  present. 

Tenderness. 

Splenic  points  of  ten- 
derness are  present. 
Pressure  on  i  he  lower 
border  of  the  spleen 
(bimanual)  is  painful. 

No     splenic 
points  of  tender- 
ness.      Tender- 
ness maybe  pres- 
ent in  the  inter- 
costal   spaces 
over  the  affected 
area.  - 

No  splenic  points 
of  tenderness. 
Tenderness  a  s  a 
rule  is  present  over 
the  affected  area. 

Rales. 

May  be  present,  due 
to  pressure  atelecta- 
sis   of  the  adjacent 
lung. 

May  be  present, 
due  to  the  asso- 
ciated   involve- 
ment of  the  sub- 
pleural    p  n  e  u - 
monic  tissue. 

Present. 

Enlargement  of 
the  spleen. 

Present  and  spleen  is 
tender  on  pressure. 

No  enlargement. 

Enlargement,  sep- 
tic in  origin,  may 
occur  late  in  the 
disease. 

Friction  rub. 

May  be  present;  gen- 
erally absent. 

Present.      Dis- 
appears   when 
effusion  occurs. 

Frequently  pres- 
ent. 

Cough. 

Generally  not  pres- 
ent. 

Present. 

Present. 

Sputum. 

None. 

Frothy  or  dry. 

Rusty. 

Temperature. 

Generally     that     of 
the  causative  lesion. 

Generally  none, 
or  very  slight. 

Generally  p^-esent 
and  vcy  high. 

*  Splenic  disorders  have  been  confused  with  acute  rheumatism,  especially 
so  when  the  splenic  pain  is  referred  to  the  left  shoulder;  but  in  rheumatism 
some  of  the  joints  are  almost  invariably  affected,  while  in  splenic  disorders  there 
is  no  joint  involvement. 


CHAPTER    XXIX 

THE  KIDNEY 

GENERAL     CONSIDERATIONS 

It  is  said  by  Howard  Kelly,  in  what  is  probably  a  fair  esti- 
mate, that  over  60  per  cent,  of  the  patients  with  ill-defined,  right- 
sided  pain  have  disease  of  the  kidney.  In  view  of  this,  it  is  easy 
to  understand  the  importance  of  being  thoroughly  conversant  with 
kidney  pains,  the  rationale  of  their  production,  and  the  method 
and  manner  of  their  perception. 

The  kidneys,  unlike  other  abdominal  viscera,  are  entirely 
retroperitoneal  and  do  not  come  in  intimate  relationship  with  the 
other  intraabdominal  viscera.  Their  position,  however,  brings 
them  into  more  intimate  contact  with  the  parietes  and  conse- 
quently with  the  nervous  supply  of  the  abdominal  walls,  which 
is  cerebrospinal.  It  is  extremely  doubtful  if  any  cerebrospinal 
fibers  convey  ner\'e  impulses  from  the  parenchyma  of  the  kidney.^ 
Yet  the  capsule  and  some  of  the  pericapsular  tissue  contain  cere- 
brospinal sensory  fibers.  In  this  way  the  localization  of  the 
aching  pain  felt  in  all  capsular  or  pericapsular  affections  can  be 
explained.  Sympathetic  nerve  fibers  supply  the  parenchyma. 
They  are  collected  into  the  renal  plexus,  which  in  turn  communi- 
cates, through  the  solar  plexus,  the  lower  and  outer  part  of  the 
semilunar  ganglion,  and  the  aortic  plexus,  with  the  lesser  and  the 
smallest  splanchnic. 

Nerve  Supply. — The  nerves  supplying  the  kidney  are  derived 

1  According  to  the  latest  researches  the  cortex  of  the  kidney  is  derived 
from  the  mesoblastic  tissue  of  the  posterior  abdominal  wall;  consequently 
there  must  have  been,  at  least  in  the  early  stages  of  development,  some  slight 
distribution  of  the  terminal  branches  of  the  spinal  nerves  to  the  kidney  sub- 
stance. Whether  these  persist  in  later  life  is  problematical. 
604, 


GENERAL    CONSIDERATIONS  605 

from  the  tenth,  eleventh  and  twelfth  dorsal,  and  the  first  lumbar 
segments  of  the  cord  (Head). 

How  important  these  areas  are  to  kidney  pain  production, 
and  how  necessary  the  knowledge  of  their  location  is  for  a  cor- 
rect and  satisfactory  diagnosis,  will  be  shown. 

Etiology  of  Kidney  Pain. — The  direct  cause  of  kidney  pain  is, 
as  in  all  painful  lesions,  an  irritation  arising  somewhere  in  the 
course  of  the  nerve  supply.  Since  the  nerve  fibers  supplying  the 
kidney  are  related  directly  and  indirectly  with  other  organs,  irri- 
tation arising  in  their  course  may  be  referred  to  any  or  all  of  these 
related  organs.  Therefore,  since  a  lesion  of  the  kidney  will  cause 
pain  and  disturbance  in  other  organs,  and  a  lesion  of  other  organs 
will  cause  pain  and  disturbance  in  the  kidney,  it  requires  more 
than  the  pain  syndrome  to  make  a  diagnosis  of  a  kidney  lesion. 
An  exception  to  this  probably  could  be  made  in  favor  of  the  local 
tenderness  which  occurs  upon  pressure  in  the  costal-vertebral 
angle,  when  the  kidney  or  the  surrounding  areolar  tissue  is  in- 
flamed. 

The  causes  and  the  locations  of  nerve  irritations  causing  kid- 
ney pain  are  varied ;  yet  it  is  most  probable  that  nearly  all  of 
the  kidney  pains  owe  their  origin  to  stretching  and  pressure  ex- 
erted upon  the  nerve  filaments  terminating  in  the  capsule. 

In  this  connection,  Watson  reports  a  case  of  apparent  renal 
colic,  in  which  the  kidney  was  opened  and  no  stone  was  found, 
but  the  capsule  was  thickened.  Complete  relief  followed  the  oper- 
ation. Keyes  also  reports  relief  from  the  splitting  of  the  capsule 
in  a  case  of  chronic  granular  kidney.  Even  in  a  simple  congestion 
the  pain  is  eased  by  capsulotomy.  However,  it  is  probable,  in 
all  cases,  that  the  pain  is  the  result  of  an  acute  process,  for  in 
chronic  and  slowly  progressing  disorders,  like  granular  nephritis 
or  new  growths  of  the  kidney,  pain  is  absent  unless  the  tension 
of  the  capsule,  from  any  cause,  is  suddenly  increased.  The  pain 
of  a  severe  and  a  colicky  type  instantly  results.  Indeed,  it  is 
claimed  by  Bcvan  and  others  that  the  pain  of  renal  calculus  is  the 
result  of  a  sudden  increase  in  intracapsular  tension.  Bevan  re- 
ports a  case  in  which,  j)revious  to  a  nephrotomy,  severe  pain  had 


606  THE    KIDNEY 

been  present,  but  was  entirely  absent  after  operation,  although  a 
stone,  which  was  present  in  the  ureter,  had  not  been  removed. 
After  the  operation  its  progress  down  the  ureter  could  be  watched 
with  the  X-raj.  At  no  time  in  its  descent  was  the  slightest  pain 
present.  This  is  only  one  of  the  many  instances  which  seem  to 
show  that  kidney  pain,  that  is,  direct  pain,  is  due  to  tension  on 
the  renal  capsule.  Should  the  capsule  be  thickened  and  non-elas- 
tic any  increase  in  the  mass  of  the  kidney  would  be  painful,  be- 
cause of  the  resistance  to  stretching  offered  by  the  thickened  cap- 
sule. For  this  reason,  it  may  be,  that  old  people  and  rheumatics 
can,  by  the  aching  which  they  have  in  their  backs  (in  the  kidney 
areas),  foretell  changes  of  weather.  The  lowering  of  the  baro- 
metric pressure  may  induce  a  kidney  hyperemia,  which  produces 
tension  of  the  capsule  and  thus  causes  pain. 

In  cases  of  intracapsular  tension,  in  which  the  renal  pelvis 
is  distended  wath  exudate,  splitting  of  the  capsule  and  opening 
of  the  pelvis  will  let  out  the  exudate  and  relieve  the  primary  pain ; 
but  a  secondary  congestion  in  the  pelvis  may  result  and  produce 
a  secondary  pain. 

An  example  of  the  insensibility  of  the  kidney  parenchyma  to 
pain  production  is  given  by  Cartwright  (Lancet,  1888,  Vol.  II, 
p.  403).  He  says  that,  when  in  China,  he  was  shown  a  speci- 
men of  a  kidney  removed  from  a  Chinese  cooley  by  an  American 
physician.  Before  its  removal  it  had  extended  through  an  open- 
ing in  the  loins  and  had  suppurated  from  the  treatment  of  bird 
dung,  saliva,  etc.,  with  which  it  had  been  daily  dressed ;  and  yet, 
during  all  this  time,  no  pain  had  been  present. 

The  kidneys  are  in  close  relation  with  the  upper  parts  of  the 
lumbar  plexus  on  either  side  and  enlargements  of  their  substance, 
new  growths,  or  perinephritic  abscesses  will  sometimes  press  upon 
certain  of  these  nerves  and  cause  pain.  This  pain  is  referred  to 
the  distribution  area  of  the  nerves  upon  which  pressure  has  been 
made.  A  more  complete  discussion  of  these  pains  will  be  entered 
into  under  the  heading  of  referred  pains  of  the  kidney. 

The  ureters  and  their  nerve  supply  will  be  considered  in  their 
respective  sections. 


GENERAL    CONSIDERATIONS  607 

Character  of  Renal  Pain. — In  some  cases,  especially  early  in 
the  renal  involvement,  a  well-defined  pain  is  not  present ;  rather, 
there  is  exjDerienced  a  sense  of  discomfort  and  distress  in  the  cor- 
responding iliac  fossa  or  lumbar  region.  This  distress  may  gradu- 
ally increase,  so  that  in  time  it  becomes  a  well-defined  pain.  If 
the  pain,  when  present,  is  of  a  dull,  aching  character,  it  indicates 
that  the  tension  on  the  capsule  is  not  of  any  considerable  moment, 
but  rather  that  the  lesion  involves  the  surrounding  renal  struc- 
tures or  is  of  some  slowly  progressing,  intranephritic  nature,  such 
as  that  which  occurs  in  the  large  white  kidney  of  nephritis.  If 
there  is  also  considerable  tenderness  on  palpation  an  extrarenal 
complication  may  be  suspected.  An  aid  of  value  in  the  diagnosis 
of  intra-  or  extrarenal  lesions  is  that  intrarenal  lesions  generally 
give  rise  to  areas  of  referred  hyperalgesia,  while  extrarenal  lesions 
do  not. 

In  some  cases  of  wandering  kidney,  from  kinking  of  the 
ureter,  there  is  a  sudden  elevation  of  the  intracapsular  pressure, 
vritli  a  very  severe,  colicky  pain.  These  attacks  go  under  the  name 
of  Dietl's  crises  (see  TTandering  Kidney).  They  are  accompa- 
nied, at  the  time  of  the  attack,  by  a  considerable  decrease  in  the 
quantity  of  urine.  This  is  followed,  on  the  reestablishment  of 
the  urinary  channel,  by  the  voiding  of  a  considerable  quantity 
of  clear  urine  which  may  be  slightly  tinged  with  blood.  During 
the  attack  palpation  will  disclose  a  swollen  and  tender  kidney. 
A  calculus  blocking  the  ureter  will  produce  similar  symptoms. 
Botli  a  kinking  of  the  ureter  and  the  blocking  of  the  same  by  a 
calculus  are  accompanied  by  vomiting  and  chills,  and,  in  some 
cases,  by  a  mild  fever. 

A  kidney  in  a  state-  of  hypertension  from  arterial  hyperemia 
has  a  peculiar  rhythmical,  pulsating  pain,  most  pronounced  in 
the  lumbar  region.  The  pain  is  synchronous  with  the  cardiac 
systole  and  is  the  result  of  the  increase  in  the  intranephritic  ten- 
sion, which  occurs  during  each  systole. 

Localization  of  Kidney  Pain.- — In  kidney  disorders,  as  well 
as  in  disorders  of  all  other  organs,  there  are  two  classes  of  pain 
manifestations,  namely:  the  subjective,  in  which  the  pain  is  pro- 


608  THE   KIDNEY 

duced  without  any  apparent  external  means  of  causation,  and  the 
objective,  in  which  pain  is  produced  by  manipulation,  pressure, 
etc.  Tenderness  comes  under  the  class  of  objective  pain.  The 
subjective  pains  may  be  divided  into  the  following  divisions: 
(1)  local,  (2)  referred,  and  (3)  reflected. 

Local  Pains. — Local  pains,  as  the  name  would  imply,  are 
those  which  are  produced  directly  in  the  kidney  area.  This  area 
is  bounded  by  (Gray)  : 

(1)  A  line  parallel  with,  and  one  inch  from,  the  spine  be- 
tween the  lower  edge  of  the  tip  of  the  spinous  process  of  the 
eleventh  dorsal  vertebra  and  the  lower  edge  of  the  spinous  proc- 
ess of  the  third  lumbar  vertebra. 

(2)  A  line  from  the  top  of  the  first  line  outward  at  right 
angles  to  it  for  2f  inches. 

(3)  A  line  from  the  lower  end  of  the  first  transversely  out- 
ward for  2f  inches. 

(4)  A  line  parallel  to  the  first  and  connecting  the  outer  ex- 
tremities of  the  first  and  third  lines  just  described. 

The  kidneys  are  therefore  opposite  the  last  thoracic  and  the 
upper  two  lumbar  vertebrae  and  reach  to  within  2.5  to  3.5  cm. 
(1  to  lYz  in.)  of  the  highest  part  of  the  iliac  crest  (Piersol). 
(See  Fig.  136.) 

Thus,  any  pain  felt  in  this  region  should  lead  at  once  to  the 
suspicion  of  disease  of  the  kidney,  especially  eo  when  the  pain  is 
associated  with  local  tenderness.  If  the  pain  is  sharply  delimited, 
and  if  referred  or  reflected  pains  are  absent,  a  perinephritic  in- 
flammatory lesion  should  be  sought. 

''This  is  most  important  to  a  correct  diagnosis  in  infants  and 
children,  because  in  them,  on  account  of  lack  of  development,  the 
ability  to  localize  pain  is  defective.  In  any  case,  either  in  them 
or  in  adults,  a  severe  abdominal  pain,  of  unknown  etiology,  espe- 
cially when  associated  with  the  drawing  up  of  the  limb,  etc., 
should  always  direct  attention  to  the  kidney." 

Beferred  Pain. — By  referred  pains  are  meant  those  pains 
which  are  felt  at  a  distance  from  the  place  where  the  irritation 
producing  them  is  located.   The  irritation  may  occur  at  any  point  in 


GENERAL    CONSIDERATIONS  609 

the  course  of  the  affected  nerve,  but  the  pain  is  perceived  as  com- 
ing from  its  peripheral  distribution  area.  In  kidney  lesions  this 
is  well  exemplified,  for  pain  due  to  the  kidney  may  be  felt  in  the 
lower  iliac  region,  the  suprapubic,  the  outer,  middle  or  the  inner 


Renal 

I  Prostate  and  seminal 
vesicles,  sexual  excess 
Bladder 
Prostate 
Seminal  vesicles 

Prostate 

Disease  of  base  of  blad- 
der 


Fig.  137. — Akeas  of  Referred  and  Reflected  Pains  in  Disease  of  the 

Urinary  Apparatus.     (Modified  from  Fenwick.) 
Unilateral  pain  of  one  fimb  is  often  a  premonitory  sign  of  brain  hemorrhage. 

part  of  the  thigh.  Pain,  Avhen  felt  in  any  other  part  of  the  thigh, 
if  it  is  produced  by  lesions  of  the  genitourinary  tract,  is  generally 
due  to  those  lesions  which  are  located  in  the  ureter  above  the 
bladder;  while  pain  felt  in  the  penis,  scrotum,  or  in  the  lateral 
margin  of  the  perineum  and  the  inner  aspect  of  the  thigh,  or  over 
the  lower  part  of  the  sartorius  muscle  (involvement  of  the  obtura- 


610  THE   KIDNEY 

tor  nerve),  generally  indicate  involvement  of  the  ureter  adjacent 
to  the  bladder. 

A  differential  point  of  value  in  the  diagnosis  of  the  location 
of  lesions  of  the  kidney  or  ureter  is  that  in  high  ureteral  in- 
volvement the  skin  of  the  scrotum  is  not  painful  to  pressure,  but 
the  deeper  tissues  are ;  while  the  reverse  is  true  in  low  ureteral 
involvement.  When  the  involvement  is  adjacent  to  the  bladder 
the  pain  may  be  referred  through  the  inferior  hemorrhoidal  nerve 
to  the  skin  around  the  anus  or  through  the  perineal  branch  of  the 
pudic  to  the  skin  of  the  scrotum.  It  may  also  be  referred  through 
the  dorsal  branch  of  the  pudic  to  the  glans  penis.  When,  in  cases 
of  renal  calculus,  pain  is  felt  in  these  areas  it  js  a  good  indication 
that  the  stone  is  in,  or  almost  in,  the  bladder.  This  is  especially 
true  should  referred  pains  in  the  lower  areas  follow  those  in  the 
upper  areas,  particularly  those  supplied  by  the  eleventh  and 
twelfth  dorsal,  the  ilioinguinal,  iliohypogastric,  and  the  genito- 
crural  nerves.  The  anterior  crural  nerve,  because  of  its  position 
behind  the  psoas  muscle,  is  fairly  well  protected  from  pressure 
from  any  kidney  or  ureteral  disorder,  and  therefore  referred  pain 
is  seldom,  if  ever,  found  in  the  region  which  it  supplies.  Another 
diagnostic  point  of  great  value  is  that  involvement  of  the  lower 
third  of  the  ureter  produces  increased  frequency  of  urination,  but 
no  pain  during  urination.  In  this  it  differs  from  lesions  of  the 
bladder,  which  cause  both  increased  urination  and  pain.  The 
zones  of  Head  are  also  of  particular  value  in  determining  the 
exact  location  of  the  lesion. 

In  some,  but  not  in  all  cases  the  progress  of  the  descent  of 
a  calculus,  and  the  distention  of  the  ureter  above  it,  can  be  noted 
by  the  referred  and  reflected  pains  which  are  present.  These  pains 
commence  above  in  the  area  of  the  tenth  dorsal  and  pass  down 
through  the  areas  of  the  iliac,  suprapubic  and  the  ilioinguinal 
to  the  scrotum  and  the  penis,  at  which  time,  as  a  rule,  the  stone 
is  in  the  bladder. 

Referred  pains  are  also  felt  in  the  thigh.  These  Schmidt 
regards  as  being  due  to  pressure  upon  the  twelfth  dorsal  nerve 
and  upon  branches  of  the  lumbar  plexus  by  thickening  of  the 


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611 


612  THE   KIDNEY 

capsule.  Such  a  causative  agent  is  a  far-fetched  possibility,  for 
though  the  amount  of  capsular  thickening  may  be  excessive  it 
would  not  by  any  means  interfere  with  the  surrounding  nerve 
structures,  unless  there  was,  at  the  same  time,  an  extensive  peri- 
nephritic  inflammation. 

For  emphasis,  even  though  it  involves  a  slight  repetition,  it 
may  be  permitted  to  recall  that  the  nerves  involved  in  referred 
pain  from  the  kidneys,  and  the  areas  which  they  supply,  are: 
(1)  the  twelfth  dorsal,  which  supplies  the  skin  of  the  lower  ab- 
dominal and  lumbar  region;  (2)  the  iliohypogastric,  (a)  iliac 
branch,  supplying  the  integument  of  the  anterior  gluteal  region, 
(b)  hypogastric  branch,  which  is  distributed  to  the  integument 
of  the  suprapubic  region;  (3)  ilioinguinal,  supplying  the  integu- 
ment of  the  upper  inner  portion  of  the  thigh;  (4)  genitofemoral, 
which  is  divided  into  (a)  genital  branch,  which  gives  branches  to 
the  skin  of  the  scrotum,  the  thigh  adjacent  to  the  scrotum,  and  the 
labia  majora  in  the  female,  and  (b)  the  crural  branch,  which 
supplies  the  upper  anterior  part  of  the  thigh,  between  the  regions 
supplied  by  the  external  cutaneous  and  the  ilioinguinal,  and  ex- 
tends down  as  far  as  the  middle  third  of  the  thigh;  (5)  the  ex- 
ternal cutaneous,  dividing  into  (a)  an  anterior  branch,  supplying 
the  integument  over  the  anterolateral  aspect  of  the  thigh  as  far 
as  the  knee,  (b)  posterior  branch,  supplying  the  skin  over  the 
tensor  fasciae  femoris  and  lower  portion  of  the  gluteal  region; 
(6)  the  obturator,  which  subdivides  into  (a)  the  anterior  branch, 
supplying  the  integument  of  lower  inner  third  of  the  thigh,  and 
(b)  the  posterior  branch,  which  by  a  branch  supplies  the  knee 
joint;  (7)  the  anterior  crural,  dividing  into  (a)  the  middle 
cutaneous,  which,  through  its  (1)  external  branch,  supplies  the 
integument  over  the  rectus  femoris  as  far  as  the  knee,  and  (2)  the 
internal  branch  also,  which  supplies  the  integument  over  the 
rectus  femoris  as  far  as  the  knee;  (b)  the  internal  cutaneous, 
supplying  the  integument  over  the  anteromedian  aspect  as  far  as 
the  knee;  and  (c)  the  internal  saphenous,  which  gives  sensation 
to  the  integument  over  the  anterior  internal  portion  of  the  leg, 
and  the  posterior  half  of  the  dorsum,  and  mesial  side  of  the  foot ; 


GENERAL    CONSIDERATIONS 


613 


(8)  the  small  sciatic,  dividing  into  (a)  the  gluteal  cutaneous, 
supplying  the  skin  of  the  inferior  gluteal  region,  as  far  externally 
as  the  great  trochanter,  and  internally  as  far  as  the  coccyx;  (b) 
inferior  pudendal,  supplying  the  skin  of  the  upper  mesial  por- 
tion of  the  thigh  and  also  the  perineal  body  and  anus;    (c)  the 


Cord 
Zones 


Dx 
Dxi 
Dxii 

Li 


9th  dorsal 
10th  dorsal 

11th  and  12th  dorsal 

ihohypogastric 

ilioinguinal 

genitocrural 

ext.  cutaneous 

middle  cutaneoua 

int.  cutaneous 

obturator 


Nerves 


FiQ.  139. — Distribution  of  Cord  Zones  (according  to  Head)  and  of 

Nerves. 

femoral  branches,  supplying  the  skin  of  the  posterior  aspect  of 
the  thigh;  (d)  the  popliteal  branches,  which  are  distributed  to 
the  popliteal  space,  and  at  times  extend  as  far  as  the  ankle; 
(9)  the  pudic,  which,  through  its  superficial  branch,  supplies  the 
lateral  margin  of  the  perineum  and  inner  aspect  of  the  thigh,  and 
the  integument  of  the  scrotum  or  labia  majora ;  and  through  the 
inferior  hemorrhoidal   branches   supplies   the   external   sphincter 


614 


THE    KIDNEY 


and  the  interment  of  the  anal  region  (Piersol,  "Anatomy,"  1st 
ed.,  pp.  1320  to  1352). 

Reflected  Pains. — In  the  lesions  of  any  visens  Head's  zones 
should  be  investigated.  Their  presence  is  of  very  great  positive, 
though  their  absence  is  of  little  negative,  value. 

It  seems  to  be  a  rule  in  kidney  disease,  as  in  disease  located 


Fig.  140. — Areas  of  Reflected  Hyperalgesia,  in  10th,  Uth,  12th  Dor- 
sal, AND  1st  Lumbar  Visceral  Segments  According  to  Head. 
These  are  the  areas  affected  in.  kidney  lesions. 

elsewhere,  that  the  first  acute  attack  of  inflammation  almost  in- 
variably produces  reflected  pain,  but  that  later  attacks  are  not  so 
prone  to  do  so,  because,  during  the  first  attack,  the  nerve  termina- 
tions are  so  much  injured  that  their  ability  subsequently  to  react 
to  pain  stimuli  is  very  much  impaired.  This  is  the  reason  why 
hyperalgesic  zones  are  not  found  in  all  cases  of  acute  or  chronic, 
recurring  inflammation.  According  to  Head,  "The  kidney  is  par- 
ticularly associated  with  the  area  of  distribution  of  the  tenth 


GENERAL   CONSIDERATIONS  615 

dorsal  segment,  and  to  a  lesser  degi'ee  with  that  of  the  eleventh 
and  twelfth  dorsal  and  the  first  lumbar  segments.  Disease  of 
the  kidney,  of  the  renal  pelvis,  and  of  the  ureter  seems  to  be  par- 
ticularly associated  with  the  eleventh  and  twelfth  dorsal  and  the 
first  lumbar  segTxiental  areas." 

The  testicle  receives  its  nerve  supply  from  the  same  segment 
of  the  cord  as  does  the  kidney,  and  therefore  re"«l  lesions  fre- 
quently give  rise  to  pain  in  the  testicle.  It  sometimes  happens 
that  the  pain  may  be  felt  entirely  in  the  distribution  area  of  the 
lower  cord  segments,  commonly  associated  witli   kidney  disease, 


Fig.    141. — Method   of  Palpation  in  Eliciting  Tenderness  in  the 

Kidneys. 

and  not  at  all  in  the  upper,  so  that  a  lesion  of  the  kidney  may 
sometimes  be  mistaken  for  one  of  the  bladder. 

Renal  pain  also  is  frequently  transferred  across  the  cord  and 
is  felt  in  the  distribution  area  associated  with  the  opposite  kidney, 
the  so-called  renorenal  reflex  of  Morris,  though  Prout  was  prob- 
ably the  first  to  draw  attention  to  this  phenomenon. 

Tenderness. — Tenderness  is  present  to  a  greater  or  less  extent 
in  nearly  every  case  of  kidney  disease.  The  only  exceptions  are 
new  growths,  which  may  be  entirely  free  of  tenderness.  The 
technique  for  examination  for  kidney  tenderness  is  as  follows : 

Have  the  patient's  bowels  tho^-o^g^ly  cle^Tised  by  a  purgative 
previous  to  the  examination;  cause  the  patient  to  recline  on  the 
back;  and  have  the  limbs  dra%vn  up,  and  raise  the  shoulders 
(preferably  on  a  pillow),  so  that  the  abdominal  walls  may  be  re- 
laxed (Fig.  141).    Place  one  hand,  palmar  surface,  over  the  lum- 


616  THE    KIDNEY 

bar  region.  Place  the  tips  of  fingers  of  the  other  hand  in  the 
subcostal  space  anteriorly;  then,  have  the  patient  take  a  deep 
breath,  and  at  the  same  time  make  simultaneous  pressure  with 
both  hands.  If  the  kidney  is  displaced  it  can  be  felt  slipping 
between  the  fingers.  If  it  is  not  displaced  it  cannot  be  felt. 
When  pressure  is  a2)plied  in  this  way  to  a  healthy  kidney  no 
pain,  though  sometimes  a  sense  of  discomfort,  is  produced; 
while,  on  the  other  hand,  if  the  kidney  is  diseased  the  patient 
immediately  complains  of  severe  pain.  Ransohoif  palpates 
simultaneously  on  both  sides,  with  the  thumbs  along  the  last 
rib  from  within  outward,  and  thus  finds  the  tender  foci.  E.  H. 
Thompson  gives  a  som.ewhat  similar  method  for  eliciting 
tenderness  in  kidney  lesions,  especially  in  renal  calculus.  ''He 
stands  behind  the  patient  and  places  the  thumbs  of  ^loth  hands 
under  the  last  ribs  and  then  so  spreads  the  fingers  over  the  abdo- 
men that  when  the  jiatient  relaxes  the  abdominal  walls,  by  bend- 
ing forward,  tlie  kidneys  are  pushed  up  toward  the  spine;  then, 
as  the  patient  straightens  up,  the  thumbs  are  strongly  pressed  in. 
If  a  renal  calculus  is  present  the  patient  will  quickly  bend  over 
to  the  affected  side." 

In  some  cases  it  occasionally  happens,  in  kidney  lesions,  that 
contraction  of  the  psoas  muscle  may  cause  pain.  This  may  be 
demonstrated  by  having  the  patient,  after  having  flexed  the  thigh 
upon  the  abdomen,  suddenly  straighten  the  limb.  The  pain,  so 
produced  by  this  maneuver,  is  deep  down  in  the  iliac  region  of 
the  side  involved. 

The  points  where  tenderness  are  most  marked  are  (1)  in  the 
subcostal  angle,  between  the  margin  of  the  erector  spinse  and  the 
last  rib;  (2)  on  the  outer  surface  of  the  thigh,  about  the  iliac 
crest;  and  (3)  on  the  abdomen,  below  the  free  margin  of  the 
tenth  rib.  The  tenderness  may  be  divided  into  tlie  superficial 
and  the  deep. 

Superficial  tenderness  and  hyperalgesia  are  useful  in  outlin- 
ing the  zones  of  Head,  while  deep  tenderness  is  a  means  of  prac- 
tical value  in  the  diagnosis  of  deeply  situated  lesions.  Should 
tenderness  be  associated  with  edema  it  is  almost  pathognomonic  of 


GENERAL    CONSIDERATIONS 


617 


a  deep-seated  inflammation.  Percussion  is  very  useful  in  exactly 
localizing  the  boundaries  of  renal  tenderness. 

Tenderness  of  the  lower  segment  of  the  ureter  can  be  deter- 
mined by  palpation  through  the  vagina  or  rectum.  In  case  of 
inflammation,  pressure  exert- 
ed upon  it  produces  pain, 
which  is  referred  to  the  same 
areas  as  is  the  pain  due  to  in- 
volvement of  the  lower  seg- 
ment of  the  bladder.  Tender- 
ness is  very  marked  in  tuber- 
culosis of  the  ureter,  or  in 
ureteropyelitic  inflammations. 
In  some  cases  a  stone,  if 
lodged  in  the  lower  segment 
of  the  ureter,  can  be  felt  from 
the  vagina  or  rectum  by  the 
palpating  finger.  The  upper 
segment  of  the  ureter  cannot 
be  satisfactorily  palpated. 

Factors  Influencing  Pro- 
duction of  Pain. — Factors  in- 
fluencing the  production  of 
pain  in  kidney  and  ureteral 
lesions  are : 

(1)  The  Position  of  the 
Patient. — The  patient  always 
assumes  the  posture  of  great- 
est ease.  In  inflammatory 
lesions  he  may  lie  on  the  side 
in  which  the  lesion  is  lo- 
cated, although  as  a  rule  he 
lies    upon    the    opposite    one. 

However,  in  nephroptosis  the  patient  is  most  comfortable  when 
lying  upon  the  healthy  side.  During  an  acute  renal  attack  he 
reclines  in  a  semi-prone  position,  with  the  back  slightly  arched. 


Fig.  142. — Position  Assumed  in 
Kidney  Disorders,  Ureteral  and 
Kidney  Colic,  Lumbago,  Uterine 
AND  Tubal  Adhesions  and  Drag 
on  Back,  Enteroptosis,  Espe- 
cially after  Removal  of  Corset. 


618  THE   KIDNEY 

and  the  limbs  flexed  upon  the  abdomen,  so  that  the  abdominal 
muscles  are  relaxed.  When  standing  the  patient  generally  bends 
forward  and  grasps  the  side  of  the  body,  pressing  in  on  the  lumbar 
region  with  the  thumbs,  and  on  the  iliac  region  with  the  flat 
of  the  hand. 

(2)  Motion  of  the  Patient  in  B elation  to  Pain  Production. — 
In  all  diseases  of  the  kidney  or  ureter  due  to  obstruction  of  the 
ureter,  or  to  an  inflammatory  process,  motion  of  any  kind  is  more 
or  less  painful.  This  is  especially  true  of  those  movements  asso- 
ciated with  shock  (vibration),  as  horseback  riding,  or  movements 
in  which  the  kidney  is  subjected  to  pressure;  for  instance,  cough- 
ing, sneezing,  deep  breathing,  rowing,  bending,  stooping,  or  the 
lifting  of  heavy  weights.  All  of  these  movements  throw  great 
pressure  upon  the  sensitized  kidney  and  so  produce  pain.  In  some 
cases  forcible  flexion  of  the  thigh  causes  pain.  This  is  due  to 
the  contraction  of  the  psoas  muscle,  causing  either  a  dragging  or 
a  pressiire  upon  the  affected  kidney. 

(3)  Duration  of  Kidney  Pain.— Pain  that  is  sharp,  sudden 
and  spasmodic,  coming  quickly  and  passing  away  just  as  quickly, 
generally  indicates  a  lesion  of  transitory  activity,  probably  a 
calculus.  Pains  of  greater  severity  and  more  constant  duration 
indicate  a  lesion  of  more  permanence  and  greater  gravity.  The 
persistence  of  tenderness  for  some  time  after  the  pain  has  ceased 
is  characteristic  of  infarct. 

Absence  of  Pain  in  Kidney  Lesions.  ^ — Pain  is  generally  absent 
in  the  following  lesions  of  the  kidney :  n'ew  growths,  acute  and 
chronic  nephritis,  and  fatty  and  amyloid  degeneration  of  the 
kidney. 

Symptoms  Associated  with  Pain  Phenomena. — Symptoms  as- 
sociated with  pain  phenomena  in  kidney  lesions  are:  (1)  muscu- 
lar rigidity,  which  is  frequent  on  the  affected  side;  (2)  frequency 
of  urination;  (3)  urinary  tenesmus;  (4)  the  presence  of  patho- 
logical products  in  the  urine;  (5)  the  presence  of  a  tumor  in  the 
kidney  region;  (6)  the  presence  of  edema,  both  localized  and 
general. 

Edema  localized  to  the  kidney  area  is  present  in  cases  of  peri- 


GENERAL    CONSIDERATIONS  619 

nephritis,  inflammation,  and  abscess  formation.  Should  edema 
be  present  nnder  the  eyes  of  those  who  complain  of  pain  in  the 
lumbar  region  it  is  a  fair  indication  of  nephritic  trouble.  Gener- 
alized edema  only  occurs  late  in  nephritic  processes. 

Pain  in  Diagnosis  of  Kidney  Lesions. — After  a  review  of  the 
anatomy,  relationship,  and  pain-producing  factors  in  kidney 
disease,  it  is  well  again  to  recall  to  mind,  in  a  brief  summary, 
the  value  of  pain  in  the  diagnosis  of  kidney  lesions.  Besides 
pain  the  principal  means  that  are  of  use  in  diagnosing  lesions  of 
the  kidney  are  the  presence  of  a  tumor  and  the  character  of  the 
urine. 

(1)  Should  pain  be  present  in  the  kidney  areas  without 
tumor, '  and  at  the  same  time  pus  should  be  found  in  the  urine, 
and  this  be  accompanied  by  a  cystitis,  with  or  without  hematuria, 
it  indicates  a  renal  tuberculosis.  If  pus  is  present  in  the  urine, 
without  cystitis,  and  with  or  without  hematuria,  renal  calculus  is 
probably  present.  The  X-ray,  as  a  rule,  will  disclose  the  stone. 
In  calculus  the  pain  is  made  worse  by  movement  and  may  be 
referred  to  the  neck  of  the  bladder.  Should  no  pus,  but,  instead, 
blood,  be  found  in  the  urine,  the  following  should  be  considered 
as  causative  factors :  cancer,  hematuric  nephritis,  papillomata  or 
angiomata  of  the  renal  pelvis,  and  renal  congestion. 

(2)  If  pain  is  present  in  the  kidney  areas  and  is  associated 
with  tumor,  the  following  should  be  inquired  into:  (a)  the 
presence  of  pus  in  the  urine,  accompanied  by  a  cystitis,  with  or 
without  hematuria,  indicates  a  hydronephrosis;  (b)  the  absence 
of  pus  in  the  urine  and  freedom  from  cystitis  and  hematuria  are 
almost  pathognomonic  of  aseptic  hydronephrosis  or  of  floating  kid- 
ney, with  or  without  moderate  retention  of  urine;  (c)  the  pres- 
ence of  a  hematuria  with  neither  pus  in  the  urine  nor  a  cystitis, 
most  frequently  points  to  cancer,  especially  if  the  hematuria 
usually  occurs  at  night  or  on  awakening.  In  all  cases  of  kidney 
involvement  the  cystoscope  should  be  used  to  tell  which  is  the 
affected  kidney. 

Pain  in  the  lumbar  region  may  be  due  to  lesions  of  other 
organs,  as  Avell  as  to  those  of  the  kidney,  and  these  should  be  diag- 


620  THE    KIDNEY 

nosed  from  kidney  lesions.  The  lesions  sometimes  so  mistaken  are 
iliosacralgia  and  iliomyalgia,  and  are  distinguished  from  kidney 
lesions  by  the  following:  (1)  they  produce  no  enlargement  in  the 
lumbar  region  and  no  tumor  can  be  felt  by  transabdominal  palpa- 
tion; (2)  stooping  and  bending  of  the  body  are  painful  and,  as 
Cathelin  has  pointed  out,  those  afflicted  by  the  above-named  condi- 
tions are  unable,  upon  arising  in  the  morning,  to  button  their 
boots  or  to  pick  up  anything  from  the  ground;  (3)  gross  urinary 
changes  are  absent. 


DIFFERENTIAL   DIAGNOSIS   OF  KIDNEY   DISEASES 
CAUSING   PAIN 

After  a  general  consideration  of  kidney  pains,  it  is  necessary 
to  particularize  and  to  review  separately  the  different  lesions. 
The  order  in  which  they  will  be  considered  is  as  follows:  (1) 
movable  kidney;  (2)  renal  infarct;  (3)  congestion;  (4)  inflam- 
mation, acute  and  chronic;  (5)  peri-  and  paranephritis;  (6) 
rupture  of  the  kidney;  (7)  tuberculosis  of  the  kidney;  (8)  new 
growths  of  the  kidney;  (9)  pyelitis;  (10)  hydronephrosis;  (11) 
renal  calculus. 

Movable  Kidney. — This  is  a  very  common  lesion.  Out  of  two 
hundred  patients  it  was  present  eleven  times,  but  in  only  one  case 
were  there  any  symptoms  referable  to  it  (Johnston).  It  is  thir- 
teen times  more  frequent  on  the  right  side  than  on  the  left.  Even 
allowing  for  its  rarity  in  the  usual  class  of  patients,  it  cannot  be 
denied  that  it  is  the  cause  of  a  large  proportion  of  the  abdominal 
discomforts  usually  encountered.  However,  frequency  of  this  con- 
dition is  probably  slightly  exaggerated  by  Kelly,  who  says  that 
sixty  per  cent,  of  the  cases  of  ill-defined,  right-sided  pain  are  due 
to  trouble  in  the  kidney,  which  trouble  is  usually  a  displacement, 
with  a  kinking  of  the  ureter  and  retention  of  the  urine  in  the 
renal  pelvis. 

Anatomical  Considerations. — Normally,  the  kidney  is  a  mod- 
erately movable  organ,  slight  elevation  and  depression  being  asso- 
ciated  with    the   up-and-down   movement    of   the    diaphragm   in 


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622  THE   KIDNEY 

breathing.  This  freedom  of  motion  is  permitted  by  the  rather 
loose  connection  of  the  kidney  with  the  surrounding  structures. 
It  is  retroperitoneal  and  is  in  close  relationship  Avith  the  dia- 
phragm. Both  kidneys  are  inclosed  in  perirenal  fascia  which 
divides  into  two  layers.  The  anterior  layer  passes  across  the 
great  vessels  and  nerves  (such  as  those  from  the  renal  plexus,  the 
solar,  eleventh  and  twelfth  dorsal,  ilioinguinal  and  iliohypogas- 
tric), and  joins  the  homologous  layer  of  the  opposite  side.  The 
posterior  layer  passes  behind  the  kidney  and  is  attached  to  the 
spine.  Above,  both  fuse  into  the  diaphragm,  while  below  they 
merge  into  the  fatty  subperitoneal  tissue  of  the  iliac  fossa.  This 
structural  formation  jDermits  considerable  up-and-down  move- 
ment, while  anterior  or  posterior  displacement  is  limited:  The 
kidneys  are  joined  on  the  right  side  to  the  liver,  colon,  and  duo- 
denum, while  on  the  left  the  colon  and  the  spleen  are  in  intimate 
relationship.  It  is  because  of  these  connections  that  displace- 
ment frequently  produces  symptoms  of  xliscomfort  and  even  of 
pain  in  these  associated  organs. 

Pathology. — In  displacement  of  the  kidney  most  of  the  pull 
is  made  upon  the  diaphragm  and  the  lumbar  fascia.  These  are 
supplied  by  the  tenth,  eleventh,  and  twelfth  intercostal  and  the 
first  lumbar  nerves.  Therefore  it  follows  that  the  pain  and  discom- 
fort in  displacement  will  be  radiated  over  the  lower  abdominal  wall 
and  the  back.  Such  is  the  case.  Yet  every  person  having  a  mova- 
ble kidney  does  not  complain  of  pain.  Indeed,  in  many  people  a 
considerable  amplitude  of  movement  and  of  displacement  are  pres- 
ent without  any  symptoms;  it  is  only  when  the  displacement  be- 
gins to  cause  disturbances  in  other  organs  that  the  patient  be- 
comes aware  of  the  pathology.  From  this  time  on  the  unfortunate 
individual  has  entered  the  realm  of  the  nephroptotic,  and  is 
subject  to  constant  distress  and  discomfort.  The  first  distress 
from  which  he  suffers  is  that  of  a  pulling  and  a  dragging  in  the 
lower  lumbar  region.  The  discomfort  may  become  so  gTcat  that 
the  patient  walks  in  a  stooping  posture,  though  this  posture  is 
more  characteristic  of  the  enteroptosis,  with  which,  as  a  rule, 
nephroptosis  is  associated,  the  nephroptosis  being  but  one  symp- 


DIAGNOSIS    OF   KIDNEY   DISEASES    CAUSING   PAIN     623 

torn  of  the  generalized  condition.  In  renal  displacement  other 
causes  for  later  pain  production  are  due  to  kinking  or  twisting  of 
the  renal  pedicle,  which  causes:  (1)  distention  of  the  renal  pel- 
vis, because  of  conij)lete  or  partial  obstruction  of  the  ureter,  and 
(2)  distention  of  the  renal  parenchyma,  because  of  renal  conges- 
tion, which  is  the  result  of  partial  obstruction  of  the  venous  flow. 
In  both  these  cases  the  pain  is  due  to  the  sudden  increase  of  intra- 
capsular pressure.  Both  simulate,  in  severity  and  suddenness  of 
onset,  the  pain  of  renal  calculus.  In  some  cases  a  movable  kidney 
may  also  be  the  seat  of  calculus,  pyelitis,  tuberculosis,  or  inflam- 
mation, and  these  give  rise  to  their  owti  typical  symptoms,  in  addi 
tion  to  those  of  the  displacement.  A  differential  point  of  value 
in  the  diagnosis  is  that  a  diseased  kidney  is  tender  on  pressure, 
while  one  which  is  only  displaced  is  not  tender. 

Location  of  the  Pain. — Local  pain  is  generally  absent  in  mov- 
able kidney,  though  there  is  present  a  constant  sensation  of  pull- 
ing or  of  dragging  in  the  lumbar  region.  In  contradistinction  to 
local  pain  is  the  frequency  with  which  referred  pains  (the  so- 
called  radiating  pains)  are  found.  They  are  due  to  the  drag  and 
pull  upon  the  nerves,  which  lie  in  close  relationship  to  the  kidney, 
such  as  the  eleventh  and  twelfth  dorsal,  the  ilioinguinal,  iliohypo- 
gastric, and,  at  times,  even  the  crural  or  the  sciatic.  Pulling  and 
dragging  on  these  cause  pain  and  discomfort  in  the  lower  abdomi- 
nal wall,  the  outer  and  inner  side  of  the  thigh,  or,  in  some  cases, 
in  the  genitalia.  The  pain  in  the  shoulder,  which  Kelly  states  is 
sometimes  present,  probably  is  due  to  traction  on  the  diaphragm, 
the  irritation  being  carried  through  the  phrenic  to  the  supra- 
acromial  nerves,  and  thence  to  their  distribution  over  the  shoulder. 
True  reflected  pain  is  seldom  found  in  displaced  kidney,  except 
when  a  state  of  very  acute  congestion,  from  venous  stasis  or 
inflammation,  occurs  in  the  affected  organ.  Then  pain  is  felt  in 
the  kidney  zones ;  in  some  cases  it  is  felt  in  the  kidney  zone  on 
the  side  opposite  to  the  one  affected.  This  pain  is  probably  trans- 
mitted through  the  sympathetic  nervous  system  to  the  cord,  and 
thence  to  the  body  wall  on  the  opposite  side. 

Kelly,  quoting  from  Moullin,  reports  a  case  where  the  pain 


624  THE    KIDNEY 

was  in  the  epigastrium,  shooting  around  to  the  back  and  shoul- 
ders. It  invariably  came  on  one-quarter  to  one-half  an  hour 
after  eating;  solid  food  made  it  worse,  vomiting  was  frequent, 
and  seemed  to  relieve  the  pain.  The  reclining  position  eased  the 
symptoms.  Kelly  quotes  this  as  a  case  of  referred  pain  from  the 
kidney,  but  it  is  difficult  to  see  why  it  is  not  one  of  gastric  ulcer. 
The  vomitus  at  times  contained  blood  and  all  the  symptoms,  man- 
ner of  pain  production,  its  reference,  and  character  would  indi- 
cate the  lesion  to  be  ulcer  of  the  stomach.  The  relief  coming 
after  the  kidney  suspension  was  due,  it  would  seem,  more  to  the 
rest  in  bed  than  to  the  operation  on  the  kidney.  In  addition  to 
the  symptoms  detailed  above  as  resulting  from  displaced  kidney, 
there  also  result  gall-duct  colic,  jaundice,  and  other  symptoms 
which  are  referable  to  the  liver  and  its  appendages,  and  are  due 
to  the  pressure  of  the  right  kidney  against  the  common  bile  duct. 

Character  of  the  Pain  in  Displaced  Kidney. — The  pain  may 
be  of  a  constant,  dragging,  or  aching  character,  and  may  be  either 
mild  or  very  severe.  In  certain  cases  it  is  so  slight  that  the  patient  is 
not  aware  of  its  presence  unless  his  attention  is  directed  to  the 
displacement.  In  other  cases  he  is  always  in  great  distress.  In 
all  cases,  when  present,  the  pain  is  made  worse  by  standing  or  by 
exercising,  and  is  generally  relieved  by  lying  down.  In  some 
women  the  pain,  as  a  rule,  is  worse  during  the  menstrual  period. 
In  others  it  is  worse  at  night  time,  after  the  removal  of  the  corset, 
while  in  still  others  it  may  be  present  when  the  patient  is  lying 
in  bed,  but  promptly  disappears  when,  on  arising  in  the  morning, 
the  corset  is  put  on.  Generally,  though,  reclining  in  bed  relieves 
the  pain. 

Paroxysmal  pains  are  also  frequent  in  kidney  displacement. 
They  were  first  described  by  Dietl  in  1864,  and  are  due  to 
torsion  or  kinking  of  the  ureter,  with  the  consequent  acute  hydro- 
nephrosis. That  such  a  twist  or  kinking  is  the  causative  agent  in 
the  production  of  the  pain  of  this  condition  would  seem  to  be 
verified  from  the  fact  that  similar  pains  may  be  produced  by  arti- 
ficial distention  of  the  pelvis  of  the  kidney  by  sterile  water.  In 
addition  i«  the  hydronephrosis,  it  is  likely  that  torsion  o'f  the  re^al 


DIAGNOSIS    OF    KIDNEY    DISEASES    CAUSING   PAIN     625 

vessels  (especially  the  vein),  by  causing  a  sudden  increase  of  the 
intracapsular  tension,  may  also  be  a  partial  factor  in  the  pain  of 
the  so-called  crises.  The  attack  is  generally  accompanied  by  nau- 
sea and  vomiting.  It  frequently  takes  place  as  a  sudden  increase 
of  existing  symptoms  and,  as  a  rule,  follows  excessive  or  violent 
motion,  either  in  the  form  of  exercise  or  in  the  jolting  incident 
to  riding  horseback,  or  journeying  in  springless  wagons  over 
rough  roads.  In  some  cases  indiscretion  in  diet  may  induce  the 
pains.  Generally,  the  attack  subsides  as  quickly  as  it  began, 
though  soreness  in  the  loin  may  persist  for  some  time.  The  at- 
tack, as  a  rule,  is  associated  with  a  weak  and  rapid  pulse,  cold, 
clammy  perspiration,  and  signs  of  collapse.  It  generally  passes 
off  in  a  few  hours,  but  may  last  for  days.  Should  the  pain  be  due 
to  torsion  of  all  the  renal  vessels,  wath  consequent  renal  conges- 
tion and  increased  intracapsular  pressure,  it  does  not  at  once  pass 
off  on  relief  of  the  condition,  but  persists  as  a  soreness  in  the 
kidney  region  for  some  time  (Johnston).  A  transient  polyuria 
follows  each  paroxysmal  attack. 

Associated  Symptoms. — The  symptoms  associated  with  mov- 
able kidney  are : 

(1)  The  Urinary  Changes. — The  urine  varies  greatly  in  the 
daily  quantity.  During  the  time  of  the  acute  torsion  the  quantity 
of  the  urine  is  decreased  and  blood,  albumin,  and  casts  may  be 
present.  Immediately  after  the  attack  the  quantity  of  the  urine  is 
greatly  increased  and  it  becomes  clearer,  though  blood  is  occa- 
sionally present,  as  well  as  albumin  and  casts.  Painful  urination 
also  is  present  at  times. 

(2)  A  tumor  due  to  hydronephrosis  may  be  noted  during  the 
attack.  It  disappears  after  the  hydronephrosis  is  relieved.  In 
some  cases  the  tumor  may  represent  only  the  kidney.  If  such 
is  the  case,  the  kidney  can  be  replaced  by  manipulation  and  the 
tumor  then  disappears. 

(3)  Digestive  disturbances,  such  as  (a)  flatulence,  which  is 
the  result  both  of  pressure  by  the  kidney  on  the  intestine  and  of 
the  transmission  of  nervous  stress  from  the  kidney  to  the  intes- 
tines, the  latter  being  due  to  the  intimate  association  of  the  two 


626  THE    KIDNEY 

organs  through  the  nervous   system,    (b)    nausea   and  vomiting, 
which  are  very  frequent. 

(4)  Constipation  may  be  due  to  pressure  on  and  obstruction 
of  the  bowel  by  the  kidney. 

Tenderness. — When  a  movable  kidney  is  pressed  between  the 
fingers  the  patient  feels  a  peculiar,  sickening  sensation,  similar 
to  that  felt  when  pressure  is  made  on  the  testicle.  If,  instead 
of  the  sickening  sensation,  pain  results,  some  inflammatory  lesion 
of  the  kidney  or  some  condition  producing  increased  intranephritio 
tension  is  present.  Factors  influencing  tlie  production  of  pain  in 
movable  kidney  are:  (1)  the  position  of  the  patient;  standing, 
especially  if  corsets  or  kidney  pads  are  not  worn,  is  provocative 
of  very  severe  distress.  Lying  down  immediately  relieves  the 
pain. 

(2)  Motion;  all  violent  motions  cause  painful  or  distressing 
symptoms.  Such  motions  as  are  present  in  jumping,  running, 
and  swimming  are  the  most  active. 

Lesions  associated  with  movable  kidney  are:  (1)  enteroptosis, 
which  is  a  commonly  associated  condition,  and  often  is  the  primary 
cause  of  the  kidney  lesion;  the  tympany,  which  may  be  present  in 
nephroptosis,  is  more  a  sign  of  the  general  enteroptosis  than  of  the 
movable  kidney;  (2)  neurasthenia  frequently  accompanies  mov- 
able kidney,  and  is  probably  due  to  the  pressure  and  pull  upon 
the  abdominal  sympatlietic  by  the  displaced  organ. 

Renal  Infarction. — In  renal  infarct  pain  is  of  gi-eat  value  in 
forming  a  diagnosis.  The  .infarction  may  be  either  septic  or 
aseptic.  In  the  septic  variety  the  embolus  is  infected  and  is  pro- 
ductive of  much  more  pain  than  is  the  non-infected  type.  Should 
the  embolus  be  infected,  after  the  infarction  has  occurred  there  is 
a  slow  increase  in  the  pain.  Pain  and  chills  of  gi-adually  increas- 
ing severity,  arising  in  a  case  in  which  they  previously  have  been 
absent,  are  signs  that  infection  has  occurred. 

Causes. — The  causes  of  pain  in  infarction  are,  according  to 
Halperin :  (1)  insult  to  the  renal  plexus,  (2)  perirenal  inflamma- 
tion or  inflammatory  reaction,  and  (3)  tension  on  the  kidney 
capsule  (Halperin). 


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628  THE   KIDNEY 

Type  of  Pain. — The  pain  is  sudden,  burning,  or  stabbing  in 
character,  and  is  entirely  free  from  any  tendency  to  paroxysms. 
It  may  be  felt  in  the  central  part  of  the  abdomen  (Johnston)  or 
may  be  without  any  definite  localization.  A  point  of  value  in  the 
diagnosis  of  renal  infarct  is  that  in  no  case  does  the  pain  radiate 
into  the  inguinal  region  or  to  the  genitalia.  Violent  motion  of 
all  kinds,  such  as  running,  jumping,  coughing,  and  sneezing,  in- 
creases it  greatly.  The  position  of  greatest  ease  is  one  in  which 
the  patient  reclines  on  the  side  of  the  lesion.  Tenderness  is 
present  over  the  affected  kidney,  particularly  toward  the  back  in 
the  costo-vertebral  angle.  Anteriorly,  the  abdominal  muscles  are 
contracted  and  render  difficult  deep  palpation,  so  that  deep  ten- 
derness is  hard  to  elicit,  although  the  diffuse  tenderness  which  is 
present  is  easily  defined.  Percussion  is  a  valuable  means  of 
diagnosis  in  this  disorder  and  more  definitely  localizes  the  tender- 
ness than  does  palpation. 

Dijferential  Diagnosis. — Conditions  causing  pain  from  which 
renal  infarction  must  be  diagnosed  are:  (1)  appendicitis,  (2) 
gastralgia,  (3)  perforative  peritonitis,  (4)  acute  ileus,  (5)  gall 
stones,  (6)  lead  colic,  (7)  embolism  of  either  of  the  mesenteric 
arteries,  (8)  gastric  crises,  (9)  lesions  of  the  kidney  or  of  the 
ureter,  such  as  (a)  torsion  of  the  ureter,  which  may  occur  in  wan- 
dering kidney,  (b)  paroxysmal  exacerbations  of  chronic  'nephritis, 
(c)  calculus  colic,  (d)  pseudocalculus  colic,  from  plugging  of  the 
ureter  with  debris,  of  either  tuberculous  or  neoplastic  origin, 
blood  clots,  or  hydatids,  or  from  obstruction  from  catarrhal  swell- 
ing of  the  mucous  membrane,  or  from  functional  spasm  of  the 
ureter. 

Associated  Symptoms. — Symptoms  associated  with  renal  in- 
farct are :  changes  and  variations  in  the  quantity  of  the  urine.  In 
the  early  stage  of  the  attack  the  secretion  of  urine  may  be  greatly 
diminished  or  may  entirely  cease.  The  urine  also  always  contains 
blood,  which,  in  the  non-infected  cases,  may  be  present  alone,  but, 
if  the  infarct  is  infected,  pus  and  bacteria  are  also  to  be  found. 
Considerable  albumin  and  epithelial  casts  are  present  in  the  urine 
during  the  early  stages  of  the  infarction.    Vomiting  and  hiccough- 


DIAGNOSIS    OF   KIDNEY   DISEASES    CAUSING   PAIN     629 

ing  are  also  common.  Frequently  there  is  a  history  of  an  asso- 
ciated or  of  a  previous  infectious  disease. 

Hematuric  Nephralgia. — Hematuric  nephralgia  (Sabattier)  is 
a  term  used  to  designate  a  pain  of  the  kidney  that  is  without 
a  definite  causative  lesion.  In  many  cases  it  seems  to  be  an 
essential  neuralgia.  That  there  is  most  probably  some  definite 
organic  basis  for  this  variety  of  kidney  pain  can  be  judged  from 
the  association  of  the  pain  with  a  hematuria.  The  productive 
agency  seems  to  be  a  congestion  of  the  active  type.  The  absence 
of  albumin  in  the  urine  in  this  disorder  does  not  argue  against 
the  presence  of  a  congestion,  for  the  kidney  may  be  extensively 
diseased  without  the  presence  of  albumin  in  the  urine,  as  has  been 
proven  time  after  time  by  examination  of  kidneys  removed  for 
nephralgia.  In  hematuric  nephralgia  one  or  both  kidneys  may  be 
affected. 

In  some  cases,  however,  hematuria  may  be  present  without 
any  accompanying  pain.  This  usually  occurs  when  coagulation 
of  the  blood  has  not  taken  place  in  the  renal  pelvis.  When  it  has 
occurred,  spasmodic  pain,  typical  of  ureteral  obstruction,  is  felt. 
This  variety  of  hemorrhage  and  pain  production  is  frequent  in 
renal  tuberculosis,  renal  tumors,  and  the  like.  A  part  of  the  pain 
present  in  renal  hemorrhage  owes  its  origin  to  distention  of  the 
renal  pelvis  with  blood. 

The  presence  of  pain  and  tenderness  in  association  with  well- 
defined  Head's  zones  may  be  of  inestimable  benefit  in  helping  to 
decide  whether  one  or  both  kidneys  are  affected  by  the  inflam- 
matory process.  The  definite  localization  is  of  very  great  prac- 
tical value  in  the  operation  of  capsulotomy  or  suspension.  Should 
only  one  kidney  be  displaced  it  is  necessary  to  sling  up  only  one, 
and  it  is  most  important  to  know  which  one. 

Inflammation  of  the  Kidney. — Inflammation  of  the  kidney  may 
be  considered  under  two  divisions:  (1)  congestion,  and  (2) 
inflammation,  which,  in  turn,  may  be  divided  into  the  acute  and 
the  chronic. 

Congestion. — Preliminary  to  inflammation  of  any  kind  is 
congestion,  which  is  very  common  and  is  frequently  encountered 


630  THE   KIDNEY 

during  ordinary  colds  and  in  various  infectious  disorders.  It  is 
of  two  types,  (a)  passive  and  (b)  active.  Passive  congestion,  as 
a  rule,  is  not  painful,  only  the  active  variety  being  so.  The  cause 
of  pain  in  active  renal  congestion  is  the  hyperemia  (induced  by 
local  irritants)  and  the  resulting  tension  on  the  capsule.  It  is  of 
a  dull,  aching  character,  and  is  made  worse  on  movement.  Deep 
breathing  seems  to  cause  more  distress  than  does  simple  motion. 
A  characteristic  point,  differentiating  congestion  pain  from  lum- 
bago, is  that  in  lumbago  the  pain  is  worse  in  the  morning  and  im- 
proves as  the  day  advances ;  while  in  congestion  the  pain  is  better 
in  the  morning  and  is  worse  in  the  evening.  Also,  the  pain  of  lum- 
bago is  increased  on  pressure  and  is  eased  by  fixation,  while  the 
kidney-congestion  pain  is  not  eased  by  fixation  with  adhesive 
straps  and  is  very  severe  on  deep  pressure.  In  acute  congestion 
disturbances  of  sensation  in  Head's  zones  are  present;  the  urine 
also  shows  the  effect  of  the  circulator}^  disturbances  and  contains 
albumin  and  casts  (blood)  to  a  variable  degree.  The  quantity 
daily  eliminated  is  also  diminished.  The  use  of  digitalis  eases  a 
passive,  while  it  increases  an  active  congestion.  There  are  all 
degrees  of  congestion.  Some  may  be  so  slight  that  they  cause  but 
the  slightest  of  transitory  disturbances,  while  others  may  be  of 
such  severity  that  they  produce  symptoms  as  severe  as  those  found 
in  inflammation. 

A  case  illustrating  the  pain  phenomena  in  congestion  of  the 
kidney  is  that  of  a  young  man  who,  at  the  time  of  the  taking  of 
the  history,  had  a  congestive  inflammatory  lesion  of  the  kidney, 
with  an  associated  pleural  effusion  which  extended  as  high  as  the 
fifth  dorsal  vertebra.  He  had  a  well-marked  hyperalgesic  zone 
extending  from  the  spine  around  the  body  to  the  right  iliac  region. 
This  hyperalgesic  area  was  thought  to  be  due  to  the  kidney.  If  it 
were  due  to  a  nephritis,  tlie  hyperalgesia  would  probably  be  bi- 
lateral; consequently  the  areas  of  hyperalgesia  would  be  present 
on  both  sides  and  would  he  somewhat  symmetrical  in  outline. 
The  areas  of  hyperalgesia  in  this  patient  were  present  only  on  one 
side  and  strapping  did  not  ease  the  pain.  (If  the  pain  was  due 
entirely  to  pleurisy,    strapping  the  chest  would   probably   havA 


DIAGNOSIS    OF   KIDNEY   DISEASES    CAUSING   PAIN     631 

eased  it.)  Consequently,  it  would  seem  that  the  condition  was 
one  of  unilateral  congestion.  The  figure  below  is  an  outline  in 
which  the  cutaneous  hyperalgesic  area  is  defined. 

IxFLAMMATiox  (Xephkitis). — Acuto  inflammation  of  the 
kidney  invariably  causes  pain,  the  intensity  of  which  depends 
upon  the  degTce  of  the  kidney  congestion  and  the  time  which  the 
kidney  has  had  to  adjust  itself  to  the  circulatory  changes.     The 


Area  of  hj-per- 
aigesia 

Area    ot    maxi- 
rcum  tender- 
ness 


12th  rib 
Area    of    maxl 
mum  tender- 
ness 

Area  of  hyper- 
algesia 


A  B 

Fig.  143.- — Area  of  Hyperalgesia  in  Congestion  of  Kidney. 


pain  is  a  much  agg-ravated  form  of  the  aching  present  in  the 
kidney  areas  when  the  kidney  is  acutely  congested.  Inflammation 
is  one  of  the  disorders  of  the  kidney  in  which  sensory  disturbances 
in  Head's  zones  are  very  plainly  marked.  Their  presence  should 
lead,  with  almost  a  certainty,  to  the  correct  diagnosis.  In  renal 
inflammation  the  urine  contains  casts  and  is  loaded  with  albumin. 
An  interesting  and  valuable  point  in  the  diagnosis  of  this  condi- 
tion is  the  co-relation  between  the  extent  of  the  Head  zones  and 
the  intensity  of  the  pain  and  tenderness  for,  as  the  hyperalgesia 
(in  Head's  zones)  becomes  less  extensive,  the  pain  and  tenderness 
also  gradually  diminish.  A  peculiarity  of  inflammatory  kidney 
pains  is  that  they  never  become  paroxysmal,  but  are  always  char- 
acterized by  dull,  constant  aching.  Stooping  is  not  painful,  but 
local  tenderness  is  marked.  A  good  way  to  elicit  tenderness  is  by 
percussion,  and  the  best  way  to  percuss  is  with  the  whole  hand, 
the  blow  being  delivered  by  the  ulnar  edge  of  the  open  hand.    The 


632  THE   KIDNEY 

referred  jDain  is  not  constant.  In  a  bilateral  lesion  it  may  be  pres- 
ent only  on  one  side,  and  in  a  unilateral  disorder  it  may  be  on 
the  side  opposite  to  the  one  involved.  The  zones  of  Head  are  of 
particular  value  in  deciding  which  of  the  two  kidney's  is  involved, 
because  they  are  jjresent  almost  invariably  only  on  the  involved 
side.  If  the  subjective  pain  should  be  on  one  side  and  Head's 
zones  should  be  present  on  the  opposite  side,  the  latter  would  be 
the  side  involved.  Tenderness  may  be  present  on  both  sides,  even 
when  only  one  kidney  is  diseased,  or  it  may  be  found  in  the  side 
opposite  to  the  one  in  which  the  diseased  kidney  is  located. 

Referred  pain  due  to  inflammation  of  the  kidney  parenchyma 
is  uncommon.  When  present  it  shows  that  the  inflammation  has 
extended  outside  of  the  capsule  into  the  adjacent  perirenal  tissues, 
and  that  a  perinephritic  abscess  has  formed. 

In  some  cases  of  nephritis  pain  is  felt  in  the  epigastrium. 
Sometimes,  also,  a  dull  aching  is  present  across  the  loins.  Rayer 
has  observed  that  in  acute  nephritis  there  is  never  any  retraction 
of  the  testicle  or  radiation  of  the  pain  into  the  groin,  such  as  are 
so  frequent  in  renal  calculus. 

In  kidney  disease  should  the  pains  become  generalized  it  is 
very  often  a  signi  of  an  early  fatal  termination,  because  general- 
ized pains  are  the  result  of  a  generalized  toxemia  rather  than  of 
the  local  process,  and  a  generalized  toxemia  occurs  only  in  the 
most  severe  and  usually  fatal  cases. 

Chronic  Inflammation. — In  contradistinction  to  acute  inflam- 
mation, chronic  inflammation,  as  a  rule,  produces  no  pain  that 
might  be  of  value  in  forming  a  diagnosis. 

Chaeactee  of  Pain  iisr  INFepheitis. — In  many  cases  nephritis 
may  be  present  for  years,  and  not  produce  the  slightest  discom- 
fort, while  in  other  cases,  very  shortly  after  its  origin,  pains  of 
great  severity,  generally  ])aroxysinal  in  type,  may  ensue.  These 
paroxysmal  pains  are  due  to  an  intermittent  congestion  of  the 
kidney.  At  the  time  of  these  congestions  blood,  as  a  rule,  is  pres- 
ent in  the  urine. 

Other  pains  associated  witn  nephritis  are  the  neuralgias  and 
the  pains  due  to  neuritis.     Headache  is  the  most  frequently  aeso- 


DIAGNOSIS    OF    KIDNEY   DISEASES    CAUSING   PAIN     633 

ciated  pain.  It  comes  on  periodically  (at  fairly  regular  inter- 
vals) and,  like  migTaine,  may  be  limited  to  one  side  (hemi- 
crania).  It  is  located  in  various  regions  of  the  head.  It  may  be 
frontal,  occipital,  temporal,  or  occipito-frontal,  the  occipital  form 
being  the  most  common.  Frequently  it  is  of  a  throbbing  char- 
acter. 

Associated  Sympto:ms. — The  s^nnptoms  accompanying  neph- 
ritis are:  (1)  the  presence  of  albumin,  casts,  and  blood  in  the 
urine,  (2)  nausea  and  vomiting,  (3)  edema,  (4)  dry  skin,  and 
(5)  slight  fever  and  (6)  a  rapid  pulse. 

Illustrative  Cases. — The  following  cases  are  intended  to 
illustrate  the  sensory  disturbances  in  Head's  zones  and  their  bear- 
ing upon  the  diagnosis  and  prog-nosis  of  nephritis. 

Case  1. — The  first  case  is  that  of  ]\Iiss  A.  ^I.  K.,  a  school 
girl   15   years  of  age,   suffering  from  subacute  parenchymatous 
nephritis.      The  illness  of  which  the  patient   complained  began 
about  six  weeks  previous,  with  shortness  of  breath,  vague  pains, 
headache,  palpitation,  coldness  of  the  extremities,  digestive  dis- 
turbances, eructations  of  foul  gases,  fetor  of  the  breath,  consti- 
pated   bowels,    pains    immediately    after    eating,    nausea,    and 
occasionally  vomiting.      The   patient  says   she  has  been  voiding 
urine,   as  a  rule,   only  once   a  day  for  the  past  six  months  and 
sometimes  not  at  all  for  more  than  twenty-four  hours.     She  says 
that  her  eyes  puff  up  in  the  morning  and  that  the  feet  and  ankles 
are  edematous.     There  is  also  some  disturbance  of  vision.     She 
has  had  measles,   chicken-pox,  whooping-cough,   and  had   scarlet 
fever  when  seven  years  of   age.      Tonsillitis  is   frequent.      The 
family  history  has  no  bearing  on  the  case.     On  physical  examina- 
tion the  patient  was  found  fairly  well  nourished,  eyes  bright,  pu- 
pillary reaction  normal;  puffiness  of  the  lower  lids,  lips  normal, 
tongue  coated;   tonsils  appear  normal,  pharynx  bulges  slightly; 
adenoids  are  present,   respiratory  disturbances  are  absent.     The 
pulse   rhythm   changes;    otherwise    it    is    full    and   rapid.      The 
heart  beats  are  normal  in  tone ;  no  valve  lesions  are  present ;  the 
abdomen  is  tender  and  slightly  tympanitic;  the  liver  and  spleen 
are  normal   in   size,   but   somewhat  tender;   gi-eat   tenderness   is 


634 


DIAGNOSIS    OF    KIDNEY   DISEASES    CAUSING   PAIN     635 


present  over  both  kidney  regions;  the  glandular  system  is  normal, 
with  the  exception  that  the  postcervical  glands  are  enlarged ;  the 
urine  discloses  hyalin  and  granular  casts,  albumin,  a  few  cells, 
and  has  a  specitic  gTavity  of  1.018.  The  patient  complains  of 
subjective  pain  sometimes  in  the  back  and  in  the  side;  at  other 
times  in  the  epigastrium.  The  blood  pressure  has  remained  at 
140  mm.  Hg.  (Stanton).  The  general  symptoms  are  probably 
due  to  the  high  vascular  tension  in  the  abdominal  organs. 


A  B 

Fig.  146. — ^Akeas  of  Hyperalgesia  in  Kidney  and  Liver  Congestion. 


Case  2. — In  the  case  of  A.  B.,  seen  in  consultation  with 
Dr.  P.,  the  kidney  areas  of  nephritis  are  well  defined  and  are 
almost  typical.  The  liver  area  is  also  present,  because, 
at  the  time  of  examination,  the  liver  was  in  a  state  of  passive  con- 
gestion. 

The  disease  began  with  a  tonsillitis  about  three  weeks  before 
the  examination  was  made.  For  the  past  two  weeks  the  patient 
has  had  no  chills  nor  fever,  though  the  tonsillar  ulceration  per- 
sists. Vomiting  was  absent  at  the  time  of  the  tonsillitis,  but  dur- 
ing the  past  week  has  been  severe,  especially  in  the  morning. 
Headache  is  present  over  the  right  eye.  It  is  a  steady,  dull  pain. 
Nose-bleed  occurred  about  six  or  seven  days  ago,  and  a  slight 
discharge  of  blood  from  the  nose  has  since  been  constantly  pres- 


636 


THE   KIDNEY 


ent.  Dizziness  is  present  at  times.  Buzzing  or  ringing  in  the 
ears  also  is  constant.  The  bowels  are  freely  movable.  The  urine, 
at  first,  was  very  slight  in  quantity,  though  at  the  present  time 
about  two  quarts  are  voided  daily.  The  patient  cannot  rest  lying 
down  and  is  compelled  to  assume  the  sitting  posture.  The  entire 
body  is  very  much  swollen  and  the  swelling  is  worse  in  the  morn- 
ing. 

Figure  146,  A,  shows  the  area  of  hyperalgesia,  A  being  that 
of  the  liver,  which  is  greatly  enlarged  and  tender;  B  and  C  the 


Hyperalgesia,  not  very 
marked 

Areas     of     hypersensitiveness 

Fig.  147. — Areas  of  Hyperalgesia  in  Nephritis.    The  letters  do  not 
correspond  to  the  letters  in  Fig.  146. 

areas  of  the  right  and  left  kidneys  respectively.  In  Figure  146 
B,  the  areas  A,  B,  and  C  correspond  to  those  for  which  A,  B,  and 
C  stand  respectively  in  Fig.  146,  A.  Notice  that  the  areas  do 
not  meet  in  the  median  line;  also  notice  the  notch  on  the  lower 
border  of  the  kidney  area,  and  how  the  lower  border  extends 
over  the  crest  of  the  ilium.  In  the  back  the  hyperalgesic  areas 
meet  over  the  median  line. 

Examination  of  the  eyes  shows  them  to  be  normal,  with  the 
exception  of  an  internal  squint  of  the  left  eye.  The  tongiie  is 
coated.  Examination  of  the  chest  exhibits  a  normal  heart. 
Fluid  in  the  pleural  cavity  is  absent. 


DIAGNOSIS    OF    KIDNEY   DISEASES    CAUSING   PAIN     637 

Fig.  1-iT  shows  the  areas  of  hyperalgesia  about  one  week  after 
the  previous  drawings  had  been  made. 

The  area  A  in  Fig.  147  A  is  becoming  smaller,  the  diminu- 
tion in  size  being  more  marked  in  the  upper  boundaries  than  in 
the  lower,  because  these  boundaries  mark  the  upper  limits  of  the 
liver  hyperalgesia  and,  at  this  time,  the  liver  was  much  smaller 
and  its  congestion  much  less;  therefore,  its  areas  of  hyperalgesia 
would  be  less.  The  other  areas  are  not  as  well  defined  as  they 
were  in  the  last  drawings,  but  they  show  a  concentric,  though  ir- 
regailar  diminution  in  size. 

In  Fig.  147,  area  B  indicates  the  hyperalgesic  zone  of  the 
liver.  This  area  lies  above  area  C,  which  was  more  hyperalgesic. 
This,  in  turn,  was  bordered  below  by  an  area  D  of  much  dimin- 
ished sensitiveness,  though  still  hyperalgesic ;  circles  in  the  fig- 
ures indicate  the  points  of  greatest  sensitiveness.  In  a  general 
way  the  patient  is  much  improved ;  the  edema  is  becoming  less 
and  the  urine  is  increasing  in  quantity.  The  throat  is  also  better. 
The  presence  of  the  referred  liver  zones  would  indicate  that  con- 
gestion of  itself  can  produce  a  Head  zone.  The  gTadual  disap- 
pearance as  the  edema  became  less  would  also  be  another  indica- 
tion of  potency  of  congestion  as  a  causative  factor  in  the  produc- 
tion of  a  Head  zone.  Why  the  area  D,  which  was  not  present  a 
week  ago,  should  be  developed  is  rather  hard  to  explain,  unless 
the  adjacent  cord  cells  became  irritated,  because  of  their  proxim- 
ity to  those  which  were  originally  involved.  This  argument  would 
seem  to  be  strengthened  from  the  fact  that  the  hyperalgesia  in 
this  area  was  not  as  acute  as  in  the  mid-area  C. 

Perinephritis. — Perinephritis  is  the  name  given  to  the  con- 
dition in  which  inflammation  is  present  in  the  perirenal  con- 
nective tissue.  This  inflammation  generally  progresses  to  the 
point  of  abscess  formation.  It  is  in  this  lesion  that  the  most  pro- 
nounced symptoms  of  any  renal  disorder  appear.  The  most  con- 
stant and  important  of  these  symptoms  is  pain  with  its  associated 
tenderness. 

Charade?'  and  Location  of  Pain. — The  pain  is  always  severe 
and  is  found  in  the  lumbar  region.     Owing  to  the  location  of  the 


638  THE   KIDNEY 

inflammation  the  lumbar  plexus  of  nerves  and  the  psoas  muscle 
are  frequently  involved  in  the  inflammatory  process.  When  the 
lumbar  plexus  is  involved,  the  pain  is  referred  to  the  distribution 
area  of  the  nerves  connected  with  it,  viz.,  in  the  cutaneous  distri- 
bution area  of  the  iliohypogastric,  the  ilioinguinal,  the  anterior 
crural,  the  obturator,  and  the  other  branches  of  the  lumbar  plexus. 
The  distribution  area  of  these  pains  is  illustrated  on  page  6Y7 
(q.V.). 

The  pain  in  some  cases  of  perinephritis  is  referred  to  the 
knee.  This  is  apt  to  cause  the  perinephritic  abscess  to  be  mis- 
taken for  a  diseased  hip.  A  reference  of  this  kind  is  very  fre- 
quent when  the  abscess  originates  at  the  lower  pole  of  the  kidney, 
for  abscess  formation  in  this  region  is  more  likely  to  make 
pressure  upon  the  anterior  crural  or  the  obturator  nerves;  these 
nerves  are  distributed  to  the  skin  of  the  lower  part  of  thigh 
(ant.)  and  the  knee,  and  when  irritated  anywhere  in  their  course 
refer  the  irritation  (pain)  thus  produced  to  these  areas. 

When  the  abscess  is  at  the  upper  pole  of  the  kidney,  the  in- 
tercostal nerves  may  be  involved  and  pain  may  be  referred  to 
their  area  of  distribution.  W^hen  the  sheath  of  the  psoas  is  in- 
volved the  abscess  progresses  downward  and  consequently  affects 
the  external  cutaneous,  the  anterior  crural,  and  the  genitocrural ; 
and  the  pain  is  referred  to  their  area  of  distribution.  At  the 
same  time,  owing  to  the  functional  relation  of  the  psoas  to  the 
thigh,  pain  on  flexion  and  extension  of  the  hip  results.  In  fact, 
motion  of  all  kinds  is  very  painful,  especially  those  movements 
in  which  pressure  is  exerted  upon  the  kidney  and  the  inflamed, 
sensitive  tissues  adjacent  to  it.  Thus,  bending  forward  or  back- 
ward is  almost  impossible. 

Tenderness. — Palpation  and  percussion  are  disagreeable  to  the 
patient.  The  tenderness  elicited  by  these  procedures  is  most 
marked  over  the  renal  area,  the  point  of  greatest  tenderness  in 
perinephritic  abscess  being  over  the  fascial  triangle  of  Grynfelt 
and  Lesshaft,  or,  as  it  is  called  by  Miller,  the  kidney  triangle.  It 
is  bounded  by  the  erector  spinse,  the  twelfth  rib,  and  the  internal 
oblique.     Here  the  kidney  is  nearest  the  surface,  and  consequently 


tc.o 

il 

History  of  a  very  severe 
I)ain.     Generally   at   the 
time  the  patient   comea 
under     observation     the 
pain  may  be  so  severe  and 
resembles    perirenal    ab- 
scess.   Pain  may  be  pro- 
duced by  the  taking  of 
food.     For  further  pain 
see  Appendicitis. 

> 

"o 
>) 

'5b  . 

2^ 

May  be  slow  or    rapid. 
Follows  an  acute  attack 
of  appendicitis. 

o 

<o 

§ 

3 

u 

o 
a 

a  « 

CD 

o  p 
2  a 

c 

o 

£ 

£ 

O 

O 

Tumor     mass     is     lower 
down  than  in  perinephri- 
tis.    Is  best  felt  from  in 
front.     Is  rather  sharply 
circumscribed. 

n 
a 

> 

H 
3 

% 
O 

a 
O 

Not  very  severe.    Tenderness 
is  most  marked  on  pressure 
made  over  the  affected  ver- 
tebra.    Very  little  tenderness 
is  felt  on  pressure  through  the 
anterior  abdominal  wall. 
Pain    may    radiate   down    to 
hi{);  when  the  abscess  reaches 
the  psoas  muscle  it  runs  along 
this  muscle  to  the  hiji. 

Fixity  of  vertebra?.    In  tuber- 
culous disease  of  the  vertebra 
kyphosis  is  present  as  a  late 
symptom. 

o 

o 

3 

'^-  a 

3 

CO 

3 

a 

No  tumor,  unless  an  abscess 
has  formed  to  one  side  of  the 
vertebra,   in  which  case  it  is 
present.  The  appearance  may 
closely    resemble    the   tumor 
mass  of  a  perinephritic  abscess. 

CQ 
PQ 
< 

a 

a 

2 

H 

Rather  severe.    Tenderness  is 
most     marked     on     pressure 
made  in  the  subcostal  angle. 
Tenderness  also  is  felt  on  pres- 
sure  made   through   the   an- 
terior abdominal  wall. 
The  pain  is  eased  by  flexion  of 
the  vertebra. 

The  pain  radiates  down  in  the 
direction  of  the  ureter. 

CI 

03 

I 

-§ 

> 
>> 

'a 

S3 
ID 

Pus;    blood    generally    found 
if    examinations    are    persist- 
ently and  carefully  made. 

c 

o 

£ 
c 
o 
U 

Presents  below  the  ribs  on  the 
side    affected    and    causes    a 
bulging  outward  on  that  side. 
The  tumor  can  be  felt  some- 
times   through    the    anterior 
abdominal  wall. 

fL| 

1 

£ 
a 

'o 

% 
•n 

£ 

a 

£ 
o 
> 

-3 

i 

CD 

u 

o 

a 

639 


640  THE   KIDNEY 

pressure  at  this  point  is  made  more  directly  upon  the  diseased 
tissue.  Pain  is  also  felt  in  other  inflammatory  diseases  of  the 
kidney  upon  making  pressure  at  this  point,  but  not  to  the  same 
degree  as  in  perinephritic  abscess.  Tenderness  on  palpation  and 
percussion  is  also  present  between  the  crest  of  the  ilium  and  the 
last  rib,  in  the  midaxillary  line,  or  somewhat  posterior  to  it. 
Should  a  localized  peritonitis  occur  over  the  inflamed  kidney  a 
marked  tenderness  to  transabdominal  pressure  will  be  found.  Ac- 
cording to  Ransohoff,  a  perinephritic  abscess  may  be  diagnosed 
from  a  kidney  lesion  proper  by  its  exquisite  tenderness  on  super- 
ficial pressure,  because,  on  the  contrary,  in  affections  of  the  kid- 
ney proper,  it  requires  deep  pressure  to  cause  discomfort.  A 
further  point  of  diagnostic  importance  is  that,  in  suppuration  of 
the  kidney  parenchyma,  pressure  made  from  in  front  through  the 
abdominal  wall  causes  considerable  pain,  while  in  perinephritic 
abscesses  the  greatest  tenderness  to  pressure  is  in  the  loin  just 
below  the  last  rib. 

Posture. — As  a  rule  the  patient  stands  with  "thighs  flexed 
on  the  pelvis.  In  order  to  relax  the  psoas  he  walks  with  body 
bent  forward  and  with  the  hand  of  the  affected  side  resting  upon 
the  upper  part  of  the  hip.  To  relax  the  part  the  trunk  is  some- 
times bent  laterally,  so  that  the  ribs  approach  the  iliac  crest" 
(Roberts,  127,  p.  392).  Roberts  believes  that  flexion  of  the  thigh 
is  an  accompaniment  of  perinephritic  abscess,  especially  if  the 
abscess  is  located  at  the  lower  third  of  the  kidney.  The  flexion 
may  be  so  slight  as  to  be  hardly  noticeable ;  in  other  cases  it  may 
be  so  severe  that  it  resists  all  efforts  at  extension.  All  other 
motions  of  the  thigh  may  be  painless. 

Associated  Symptoms. — Other  symptoms  of  value  in  the  diag- 
nosis of  a  perinephritic  abscess  are : 

(1)  The  presence  of  a  localized,  fluctuating  swelling  in  the 
lumbar  region.  The  three  cardinal  features  of  this  swelling, 
which  render  its  identification  as  a  kidney  lesion  easy,  are  as 
follows:  (a)  it  lies  entirely  on  the  posterior  wall  of  the  abdomen 
and,  even  when  very  large,  does  not  approach  the  anterior  ab- 
dominal wall;  (b)  it  is  diffuse  and  is  not  confined  to  the  region 


DIAGNOSIS    OF    KIDNEY    DISEASES    CAUSING   PAIN     641 

of  the  kidney  proper;  its  limits,  also,  cannot  easily  be  defined; 
(c)  it  is  not  influenced  by  respiration  (a  kidney  enlargement  due 
to  disturbance  in  the  parenchyma  of  the  kidney  will  move  with 
respiration). 

(2)  Aspiration  of  the  tumor  mass  generally  reveals  pus. 

(3)  Gastrointestinal  symptoms,  such  as  vomiting,  tympany, 
and  constipation,  are  present. 

(4)  Jaundice  sometimes  occurs  in  perinephritic  abscess  on 
the  right  side. 

(5)  There  is  frequently  a  history  of  an  injury  or  of  a  renal 
infarction.  In  the  first,  trauma  is  followed  at  first  by  renal  ten- 
derness, then  by  chills,  and  fever,  and  lastly  by  the  tumor. 

(6)  In  some  cases  there  is  a  fixation  of  the  lumbar  spine  with 
scoliosis,  the  concavity  being  on  the  side  of  the  diseased  kidney. 

(7)  When  the  sheath  of  the  psoas  is  involved  extension  of  the 
limb  on  the  affected  side  is  painful,  while  at  the  same  time  all 
other  movements  can  be  made  without  pain.  This  differentiates 
it  from  hip-joint  disease. 

(8)  A  characteristic  of  perinephritic  disease  is  the  high  white 
blood  count   (Morris,  Booth,  Miller). 

(9)  Painful  breathing,  coughing,  sneezing,  etc.,  are  some- 
times present  and  may  be  due  to  involvement  of  the  pleura. 

Retraction  of  the  testicle  tow^ard  the  affected  side  has  been 
given  as  an  important  sign;  but  according  to  Xieden  it  does  not 
occur  unless  a  calculus  nephritis  is  present  in  addition  to  the  peri- 
nephritic abscess.  This  statement  is  doubted  by  Roberts  (127, 
p.  392).  When  it  occurs  the  retraction  is  due  to  involvement  of 
the  genitocrural  nerve  (Roberts,  p.  405). 

Differential  Diagnosis. — Perinephritic  inflammation  may  be 
confused  with  pleurisy.  Hepatitis  should  be  differentiated  from 
perinephritis  on  the  right  side;  splenitis  from  perinephritis  on 
the  left.  Pneumonia  also  is  sometimes  mistaken  for  perinephritis. 
It  should  also  be  diagnosed  from  osteomyelitis  of  the  vertebra 
and  appendicitis  with  abscess  formation. 

Rupture  of  the  Kidney. — While  rupture  of  the  kidney  with- 
out pain  has  been  reported,  it  is  almost  inconceivable  how  this 


642  THE   KIDNEY 

severe  lesion  could  occur  without  producing  at  least  some  pain. 
The  rupture  may  tear  into  the  perinephritic  tissue ;  when  it  does 
so  there  is  felt  a  sudden,  sharp  pain,  not  restricted  to  any  area, 
but  generalized  and  diffuse.  If  the  rupture  is  such  that  hemor- 
rhage takes  place  into  the  pelvis  of  the  kidney  severe  pain, 
paroxysmal  in  type,  ensues,  and  is  due  to  the  passage  of  blood 
clots  down  the  ureter.  At  the  same  time  there  is  a  transitory 
hydronephrosis.  One  of  the  surest  of  the  confirmative  signs  of 
rupture  is  hematuria ;  however,  there  is  an  exception  in  slight 
rupture  of  the  cortex,  in  which,  unless  there  is  a  concomitant 
injury  to  the  pelvis,  blood  may  not  be  present  in  the  urine. 

Following  the  rupture,  if  it  has  not  proved  fatal,  a  perineph- 
ritic abscess  generally  develops. 

Tuberculosis  of  the  Kidney. — Tuberculosis  of  the  kidney  may 
or  may  not  be  painful.  In  some  cases  pain  is  present  only  in  the 
terminal  stages  of  the  disease,  while  in  others  it  may  be  one  of 
the  earliest  symptoms.  According  to  Maylard  pain  is  absent  as 
long  as  the  lesion  is  confined  to  the  parenchyma,  and,  when  pain 
is  present  in  the  early  stages,  it  is  more  vesical  than  renal  in 
origin.  When  present  it  occurs  before  and  after  urination  and 
is  associated  with  increased  frequency  of  tlie  urinary  act.  In 
these  cases  the  symptoms  are  such  that  even  in  a  normal  bladder 
cystitis  might  be  diagnosed.  In  all  advanced  cases,  however, 
it  is  found,  and  should  it  be  present  in  the  absence  of  gonorrhea, 
trauma,  instrumentation,  or  stone,  it  must  be  looked  upon  as  jore- 
sumptive  evidence,  especially  in  the  young,  of  renal  tuberculosis 
(Ransohoff). 

Character  of  the  Pain. — When  the  disease  is  fairly  well  ad- 
vanced pain  is  a  most  important  symptom.  It  is  localized  to  the 
side  of  the  kidney  and  may  radiate  to  the  inguinal  or  to  the  iliac 
regions.  It  may  be  i:)roduced  spontaneously  or  be  felt  only  on 
pressure.  According  to  Brazy,  the  three  points  on  the  anterior 
abdominal  wall  where,  in  renal  tuberculosis,  pain  is  most  likely 
to  be  produced  on  pressure  are  the  paraumbilical,  the  subcostal, 
and  the  lumbar  (Figs.  148  and  149).  If  the  tuberculous  process 
advances  beyond  the  capsule  and  invades  the  paranephritic  tis- 


DIAGNOSIS    OF   KIDNEY   DISEASES    CAUSING   PAIN     643 

sues,  the  pain  and  tenderness  in  the  costovertebral  angle  become 
excessive.  In  tuberculosis  of  the  kidnej  Head's  zones  of  reflected 
hyperalgesia  are  sometimes  present.  When  present  they  are,  as  a 
rule,  synchronous  with  the  so-called  ureteral  colic,  due  to  the  pas- 
sage of  detritus,  blood  clots,  pieces  of  necrotic  tissue,  etc.,  through 
the  ureter.  The  tissue  and  clots  block  the  ureter  and  distend  the 
pelvis  of  the  kidney  either  with  urine  or  with  blood.  The  intra- 
nephritic  pressure  now  becomes  excessive  and  it  is  to  this,  and  not 
to  spasm  of  the  ureter,  that  the  jDain,  paroxysmal  in  type,  is  due. 


Areas  of  tenderness  in 
renal  tuberculosis 


Areas  of  tenderness  in 
renal  tuberculosis 


Figs.  148  and  149. — Areas  of  Tenderness  Present  in  Renal  Tuber- 
culosis. 


There  are  two  types  of  pain  in  renal  tuberculosis.  The  first  is 
the  constant,  steady,  aching  pain,  which  may  be  interrupted  by 
the  paroxysmal  pains,  the  second  type.  In  some  instances,  sud- 
den, acute,  paroxysmal  pain  may  be  present  without  obstruction 
of  the  ureter  by  clots  or  by  pieces  of  necrotic  tissue  or  other  ele- 
ments. It  is,  then,  probably  due  to  an  acute  congestion  of  the 
kidney,  with  a  great  increase  in  the  intracapsular  tension.  For- 
tunately for  the  comfort  of  the  patient,  these  paroxysmal  attacks 
are  rare. 

In  kidney  tuberculosis  tubercle  bacilli  often  can  be  discovered 
in  a  centrifugalized  specimen  of  urine  obtained  by  ureteral  cathe- 
terization. 


644  THE   KIDNEY 

In  many  eases  the  tubercnlons  disease  of  the  kidney  may  not 
produce  any  well-marked  pain,  bnt  rather  a  diffuse  aching,  discom- 
fort, or  a  dragging  sensation  in  the  lumbar  region.  As  sometimes 
happens  in  other  varieties  of  kidney  disease,  the  pain  and  distress 
may  be  referred  to  the  kidney  area  on  the  side  opposite  to  the  one 
affected. 

Diagnosis. — Pain  in  the  kidney  region,  in  those  cases  in  which 
tuberculosis  is  present  in  other  parts  of  the  body,  should  always 
lead  to  the  suspicion  of  a  probable  tuberculosis  of  the  kidney. 
The  diagnostic  signs  of  tuberculosis  of  the  kidney  are : 

(1)  The  presence  of  the  characteristic  pain. 

(2)  The  discovery  of  blood,  pus,  cells  and  tubercle  bacilli  in 
the  urine.  In  some  cases  the  presence  of  blood  in  the  urine  may 
precede  other  symptoms  of  the  disease  for  many  years.  Precipi- 
tancy of  urination  is  frequently  present. 

(3)  Elevation  of  temperature  is  present  in  a  fair  proportion 
of  cases. 

(4)  Increased  rapidity  of  the  pulse  is  common.  It  generally 
varies  with  the  fever  and  is  of  a  hypotension  type. 

(5)  Lung  symptoms,  or  signs  of  tuberculosis  in  other  regions 
of  the  body,  are  often  found. 

(6)  Enlargement  of  the  kidney  is  generally  an  early  symp- 
tom. The  kidney  is  tender  to  pressure,  and  since  the  enlarge- 
ment is  commonly  due  to  pyonephrosis  it  varies  with  the  painful 
crises. 

(7)  V.  Pirquet,  subcutaneous,  and  Calmette  reactions  for  tu- 
berculosis are,  as  a  rule,  present. 

New  Growths. — New  growths  of  the  kidney  are  of  two  types, 
the  benign  and  the  malignant.  In  either  case,  pain  is  not  a  symp- 
tom of  much  value.  The  benign  growths  causing  pain  are  cystic 
in  character,  and  may  consist  of  simple  cysts,  polycysts,  or  hyda- 
tids. The  malignant  growths  are  sarcoma,  carcinoma,  and  hyper- 
nephroma (Grawitz'  tumor). 

Etiology. — The  pain  in  all  of  these  conditions  is  due: 
(1)  To  the  dragging  upon  the  surrounding  tissues  by  the  kid- 
ney, because  of  its  increased  size  and  weight. 


DIAGNOSIS    OF   KIDNEY    DISEASES    CAUSING   PAIN     645 

(2)  To  an  increase  of  intracapsular  pressure,  from  (a)  a 
hydronephrosis,  the  result  of  a  kinking  of  the  ureter  from  a  ptosis 
of  the  kidney,  or  a  blocking  of  it  by  a  blood  clot  or  a  par- 
ticle of  the  malignant  tissue;  (b)  increase  in  the  size  of  the 
growth  (a  slow  and  gradual  increase  in  size  is  not  painful,  it  is 
only  when  the  increase  is  sudden  that  the  pain  is  pronounced)  ; 
(c)  a  hemorrhage  into  the  substances  of  the  growth  or  into  the 
parenchyma  of  the  kidney.  This  occurs  more  frequently  in  sar- 
coma and  carcinoma  (Johnston)  than  in  other  growths.  Indeed, 
it  is  claimed  that  in  these  growths  pain  is  not  produced  unless  an 
intracapsular  hemorrhage  has  occurred.  Sometimes,  when  the 
new  growth  penetrates  the  pelvis,  hemorrhages  ensue  and  hema- 
nephrosis,  with  its  consequent  pain,  results. 

(3)  Contracting  abdominal  muscles,  also,  may,  by  pressing 
upon  tender  kidneys,  cause  pain. 

Chakactek  of  the  PAijf  IX  Xew  Growths  of  the  Kidney. 
— The  sensation  present  in  these  disorders  is  rather  an  aching 
and  discomfort  than  actual  pain,  though  at  times,  when  the 
intracapsular  tension  is  greatly  increased,  the  pain  becomes 
most  acute  and  assumes  a  paroxysmal  character.  Because  as  a 
rule  only  one  kidney  is  involved  the  pain  is  unilateral.  It  may  be 
caused,  and  in  most  cases  is  aggTavated,  by  violent  movements, 
such  as  jarring,  the  lifting  of  heavy  objects,  or  the  carrying  of  a 
heavy  weight.  The  pain  may  radiate  to  the  thigh.  This  radia- 
tion is  due  to  the  pressure  exerted  upon  the  lumbar  plexus  by  the 
enlarged  and  heavy  kidney. 

Vaeieties  of  jSTew  Growths. — Cystic  Disease. — (1)  Simple 
Cysts. — In  these  conditions  the  pain  has  been  known  to  precede 
the  formation  of  the  cyst.  When  the  cyst  has  formed  the  pain  is 
of  a  dull  aching  type,  and  is  varied  with  sharp  paroxysms,  which 
are  associated  with  enlargement  of  the  kidney.  These  exacerba- 
tions are  probably  due  to  a  hemorrhage  into  the  substance  of  the 
cyst. 

(2)  Polycystic  Disease. — In  this  disorder,  if  only  one  kidney 
is  diseased,  the  pain  is  on  the  diseased  side.  Should  both  kidneys 
be  affected  the  pain  is  bilateral.     It  may  be  constant  or  intermit- 


646  THE    KIDNEY 

tent,  is  less  when  the  patient  rests  in  bed  and  is  quiet,  and  is  very 
much  increased  upon  movement.  As  in  simple  cysts,  hemorrhage 
may  occur  into  the  substance  of  the  growth  and  produce  great  pain. 
Considerable  tenderness  on  pressure  is  present  in  the  costoverte- 
bral angle.  The  diagnostic  symptoms  associated  with  a  polycystic 
growth  of  the  kidney  are  (a)  the  presence  of  a  tumor  (kidney), 
which  is  mobile  and  contains  knobs  on  the  surface,  and  (b)  the 
character  of  the  urine,  which  is  increased  in  quantity,  is  of  low 
specific  gravity,  and  contains  a  slight  amount  of  albumin,  casts, 
and  blood.  It  also  contains  bodies  resembling  those  found  in  the 
prostate. 

(3)  Hydatid  Disease. — In  this,  as  a  rule,  pain  due  to  sti*uc- 
tural  kidney  change  is  absent ;  but  in  its  stead  is  colic,  due  to 
blocking  of  the  ureter  by  the  booklets.  These  booklets  can  some- 
times be  detected  in  the  urine. 

(4)  Sarcoma  of  the  Kidney. — This  gives  rise  to  pain  of  a 
dull,  dragging  character,  referred  to  the  lumbar  region  or  to  the 
thigh.  Paroxysms  of  colic  occur  when  the  ureter  is  temporarily 
blocked  by  blood  clots  or  by  pieces  of  sarcomatous  tissue. 

(5)  A  hypernephroma  may  be  without  pain.  Its  onset  may 
be  so  insidious  that  its  presence  is  not  discovered  until  the  size 
of  the  tumor  draws  attention  to  the  condition.  Then  pain  may 
ensue  and  aggravate  further  the  discomfort  and  distress  of  the 
patient.  The  pain  may  be  constant,  dull,  and  aching,  or  it  may 
be  paroxysmal,  the  paroxysms  occurring  when  the  kidney  capsule 
is  subject  to  considerable  intranephritic  tension,  either  from  back- 
ward stasis  of  the  urine  (a  clot  in  the  ureter)  or  from  hemorrhage 
either  into  the  parenchyma  of  the  kidney  or  of  the  tumor.  The 
pains  may  radiate  into  the  pelvis  or  down  into  the  thighs.  Both 
the  kidney  and  the  related  tumor  as  a  rule  are  very  tender  to 
pressure.     Hematuria  is  the  most  frequent  associated  symptom. 

Diagnostic  Symptoms. — Tumors  of  the  kidney  have  the 
following  diagnostic  symptoms  (Piersol  and  Morris)  : 

(1)  The  large  intestine  is  in  front  of  the  tumor.  This  does 
not  happen  with  liver  or  splenic  tumors.  If  the  colon  is  distended 
with  ga'^  it  produces  a  tympanic  mass  anterior  to  the  tumor,  while 


DIAGNOSIS    OF   KIDNEY    DISEASES    CAUSING    PAIN     647 

if  collapsed  it  can  often  be  felt  as  a  roll  of  tissue  beneath  the 
fingers. 

(2)  Eenal  tumor  causes  an  anterior  bulging  into  the  abdo- 
men. A  posterior  bulging  generally  indicates  a  periuephritic 
abscess. 

(3)  1^0  area  of  resonance,  such  as  is  found  in  tumors  of  the 
spleen,  is  present  between  the  dulness  of  the  tumor  mass  and  the 
vertebrae. 

(4)  A  kidney  tumor  retains  somewhat  the  shape  of  the  kidney. 

(5)  It  generally  does  not  reach  the  midline. 

(6)  There  is  an  area  of  resonance  on  the  right  side  between 
the  dulness  of  the  liver  and  that  of  the  kidney. 

(7)  Varicocele  is  often  present  on  the  side  of  the  tumor. 

(8)  The  tumor  generally  does  not  extend  into  the  pelvis,  and 
generally  does  not  move,  to  any  considerable  degree,  with  respira- 
tion. 

Associated  symptoms  may  also  be  produced  from  obstruction 
of  the  colon  and  also  from  traction  on  the  spleen,  the  liver,  or  the 
diaphragm. 

Pyelitis. — Character,  Causation,  and  Localization  of 
Pain. — In  pyelitis  pain  may  or  may  not  be  present,  although  in 
about  seventy-five  per  cent,  of  the  cases  it  is  manifested  at  some 
time  during  the  course  of  the  disease.  The  pain  is  more  severe 
in  the  acute  varieties,  or  in  exacerbations  of  the  chronic  forms. 
These  exacerbations  are  sometimes  the  result  of  cooling  of  the 
surface,  such  as  occurs  in  getting  drenched,  or  even  in  having 
the  feet  wet  or  damjD,  and  in  being  exposed  to  drafts  or  to  chill' 
ing.  The  chilling  of  the  surface  drives  the  blood  inward  and  pro- 
duces a  congestion  of  the  already  inflamed  kidney,  with  an  exacer- 
bation of  the  pain.  The  pain  usually  is  felt  in  the  back  (in  the 
kidney  areaj,  and  has  a  tendency  to  radiate  to  the  thigh,  the  peri- 
neum, the  genitalia,  or  upward  to  the  epigastrium  or  shoulder. 
It  is  generally  increased  by  pressure. 

It  is  possible  that  pyelitis  of  itself  does  not  produce  pain  un- 
less there  is  a  concomitant  involvement  of  the  kidney  paren- 
chyma.    When  such  involvement  occurs  a  slight  tensiot*  of  the 


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DIAGNOSIS    OF    KIDNEY    DISEASES    CAUSING   PAIN     649 

capsule  may  result,  and  both  subjective  and  objective  pain  be 
felt.  The  pain  may  appear  in  the  form  of  an  aching  in  the  back, 
or  of  tenderness  over  the  diseased  kidney. 

These  renal  pains  may  be  followed  or  accompanied  by  ureteral 
colic,  due  to  the  blocking  of  the  ureter  by  debris.  This  variety 
of  ureteral  colic  is  hard  to  differentiate  from  calculus  colic.  A 
means  of  distinguishing  it  is  by  the  X-ray,  which  defines  a  shadow 
if  a  stone  is  present ;  or  by  the  wax-tipped  catheter,  which  shows 
a  scratch  should  stone  be  encountered.  If  the  pain  changes  to  a 
dull,  constant,  or  possibly  throbbing  type  and  chills  and  fever 
appear,  it  is  an  indication  that  a  pyelonephrosis  or  a  renal  abscess 
is  forming  or  has  formed. 

Pyelonephrosis  and  Parenchymatous  Infection. — In- 
flammation of  the  kidney  pelvis  of  itself  may  not  produce  pain 
symptoms  until  some  secondary  complication  such  as  (1)  pye- 
lonephrosis or  (2)  parenchymatous  infection  takes  place.  The 
former,  pyelonephrosis,  produces  symj^toms  that  resemble  in  their 
complex  the  paroxysms  of  ureteral  colic.  Both  have  the  same  etio- 
logical relationship  to  pain  production,  which  is  due  to  ureteral 
obstruction.  This  obstruction  may  be  caused  by  blood  clots,  fibrin, 
pus,  necrotic  tissue,  inflammatory  swelling,  or  organized  exudates. 
A  peculiarity  worth  remembering  is  that  pyelonephritic  pains 
generally  precede  the  parenchymatous  ones.  Parenchymatous  in- 
volvement also  causes  pain  symptoms  which  we  have  learned  to 
associate  especially  with  kidney  involvement.  It  is  likely  that 
the  irritation  of  the  parenchyma  gives  rise  to  sensory  signs  in 
the  Head  zones,  Avhile  the  capsule  tension,  also  due  to  the  paren- 
chyma involvement,  causes  the  achings  so  constantly  found  in  the 
lumbar  region. 

Therefore,  in  pyelonephrosis  or  in  hydronephrosis,  the  p9,in  is 
due  both  to  ureteral  spasm  and  to  capsule  stretching,  and  Head's 
zones  will  be  absent,  while  in  parenchymatous  involvement  Head's 
zones  and  the  capsule  tension  pains  will  be  present,  while  the  col- 
icky pains  are  almost  invariably  absent. 

Differential  Diagnosis. — One  is  likely  to  err  in  the  diag- 
nosis of  lesions  of  the  kidney  or  of  the  upper  part  of  the  ureter. 


550  THE   KIDNEY 

because  involvement  of  the  upper  part  of  tbe  ureter  causes  the 
pain  areas  to  be  so  distributed  tbat  they  correspond  to  tbe  kidney 
zones.  Yet  if  it  is  borne  in  mind  tbat  a  ureteral  colic  cannot  be 
due  to  a  lesion  of  tbe  kidney  witbout  ureteral  obstruction,  tbe  con- 
clusion may  be  reacbed  tbat  tbe  lesion  is  of  sucb  a  nature  tbat  it 
involves  both  tbe  kidney  and  tbe  ureter.  Sbould  pain  be  present 
in  tbe  kidney  area  prior  to  its  presence  in  tbe  ureteral  area,  and 
sbould  tbe  latter  become  manifest  only  during  a  severe  colic,  or 
sbould  pain  in  tbe  ureteral  area  disappear  after  tbe  colic,  witb  tbe 
persistence  of  a  kidney  zone,  a  lesion  of  tbe  kidney,  wbicb  causes 
intermittently  a  renal  colic,  may  be  diagnosed.  Among  sucb 
lesions  are  tbe  following: 

(1)  Pyelitis  or  Pyonephrosis. — In  tbese  conditions  colic,  due 
to  tbe  passage  tbrougb  tbe  ureter  of  masses  of  exudate,  sucb  as 
collections  of  fibrin,  or  pieces  of  kidney  substance  wbicb  bave  be- 
come disorganized  and  cast  off,  is  sometimes  present.  Kidney 
and  ureteral  zones  are  both  present.  Tbe  kidney  zone  persists 
after  tbe  obstruction  bas  been  removed,  wbile  tbe  ureteral  zone 
disappears. 

(2)  Penal  Calculus. — Here  tbe  pain  comes  on  quite  sud- 
denly, and  tbe  ureteral  zone  and  tbe  kidney  zone  from  tbe  asso- 
ciated bydronepbrosis  are  botb  present.  Wben  tbe  obstruction  is 
removed,  and  tbe  dammed-up  fluid  escapes,  tbe  kidney  and  ureteral 
zones  disappear  simultaneously. 

In  pyelitis,  pyonepbrosis,  and  ureteral  calculus  an  intermit- 
tent bydronepbrosis  occurs,  and  on  bimanual  examination  tbe 
physical  signs  associated  witb  it  are  found.  Sucb  signs  are:  (1) 
tumor,  wbicb  is  in  tbe  kidney  region,  and  wliicb  increases  in 
size  during  tbe  period  of  colic,  to  rapidly  decrease  in  size  on  tbe 
subsidence  of  tbe  colic;  (2)  subjective  pain  in  tbe  back  over  tbe 
location  of  tbe  kidney;  (3)  tenderness  to  deep  pressure  over  tbe 
kidney  region,  tbe  tende'rness  being  especially  well  marked  at  tbe 
time  of  tbe  bydronepbrosis. 

It  is  easy  to  understand  bow  difficult  it  is  definitely  to  decide 
from  tbe  pain  complex  tbe  character  of  tbe  Iddney  involvement, 
and  tbe  stage  at  which  it  rests.     But  with  constant  endeavor  aric 


DIAGNOSIS    OF   KIDNEY   DISEASES    CAUSING   PAIN      651 

close  application  in  nearly  all  cases  it  is  possible  to  do  so.  For  a 
proper  realization  of  tlie  non-importance  of  their  absence  it  must 
be  recalled  that  disturbances  in  Head's  zones  are  not  constantly 
present,  esj)ecial]y  so  should  the  attack  under  observation  be  only 
one  of  a  series  which  has  preceded  it.  During  the  preceding 
attacks  the  nerve  filaments  may  have  been  destroyed  to  such  an 
extent  that  subsequently  they  are  not  able  to  carry  stimuli.  Thus 
they  are  not  able  to  respond  to  irritation.  This  is  the  reason  why 
the  Head  zones  are  so  often  absent  in  parenchymatous  involve- 
ment. 

Pyelitis  in  Pregnancy. — Pyelitis  is  frequent  in  pregnant 
women,  and  is  due  to  the  pressure  of  the  pregnant  uterus  upon 
the  ureter,  with  a  consequent  stasis  and  infection  of  the  urine. 
As  a  rule  the  infection  comes  from  the  adjacent  colon. 

In  these  cases  pyonephrosis  accompanies  the  pyelitis,  and  all 
the  signs  and  symptoms  usually  associated  with  the  former  are 
present.  However,  inflammation  of  the  renal  pelvis  itself  does 
not  cause  pain  unless  there  is  a  concomitant  obstruction  of  the 
ureter  by  the  pregnant  uterus  (Pilcher).  To  produce  pain  it  is 
not  necessary  that  the  pyonephrosis  be  severe ;  in  some  cases  a 
very  slight  distention  will  cause  the  most  severe  pain.  A  pelvis 
containing  only  one  ounce  of  pus  has  been  known  to  produce  con- 
siderable pain.  The  reason  for  this  is  that  the  existing  inflamma- 
tion of  the  pelvis  has  penetrated  to  the  parenchyma,  and  has 
caused  it  and  the  capsule  to  be  more  sensitive  to  stretching,  and  to 
react  with  pain  production  to  a  lesser  threshold  pressure  than 
they  would  in  their  normal  condition.  The  hydronephritic  symp- 
toms may  be  intermittent.  They  may  disappear  for  a  time  only 
again  to  reappear  with  increased  intensity. 

Symptoms  Associated  with  Pyelitis. — In  pyelitis  a  careful 
examination  of  the  urine  is  most  essential  to  the  making  of  a 
proper  diagnosis.  The  presence  of  pus  cells  in  the  bladder  urine 
is  not  of  such  special  diagnostic  import  as  are  pus  cells  found 
in  a  specimen  of  urine  catheterized  from  the  ureter.  Ureteral 
catheterization  also  gives  a  clear  indication  of  the  kidney  which  is 
involved.     The  temperature  in  pyelitis,  as  a  rule,  has  a  typical 


652  THE    KIDNEY 

septic  curve.  In  some  cases  the  temperature  curve  is  present  for 
some  days  before  the  attack  of  pain.  Chills  are  generally  coin- 
cident with  the  paroxysmal  pains.  They  are  due  to  the  absorp- 
tion of  septic  material  from  the  dammed-up  urine. 

Owing  to  the  sympathetic  relationship  of  the  bladder  and 
the  kidney,  secondary  bladder  symptoms,  or  rather  preliminary 
bladder  symptoms,  since  in  nearly  all  cases  they  precede  the  other 
symptoms,  are  frequent.  The  symptoms  especially  associated  with 
the  bladder  are  frequency  and  difficulty  of  urination. 

Pyoneijhrosis  is  an  advanced  type  of  pelvic  inflammation  in 
which  a  retention  of  urine  from  ureteral  obstruction  has  taken 
place.  In  the  very  early  stages  of  this  condition  the  pain  is  not 
different  from  that  present  in  the  lesion  from  which  the  pyone- 
phrosis originated.  Later,  pain  typical  of  a  hydronephrosis  occurs. 
The  inflammatory  process  now  travels  through  the  tubules  into 
the  parenchyma  of  the  kidney  and  a  general  inflammation  of  the 
kidney  structures  ensues,  the  so-called  pyelonephritis.  However, 
a  hydronephrosis  does  not  always  precede  the  formation  of  a 
pyonephrosis;  the  preceding  condition  may  have  been  a  pyelitis, 
without  any  accumulation  of  fluid  in  the  renal  pelvis.  When 
pyelitis  is  present  without  pelvic  distention,  pain  is  absent,  and 
only  comes  on  when  the  pelvis  of  the  kidney  begins  to  dilate,  and 
tension  is  made  upon  the  kidney  capsule,  when  a  diffused,  dull 
aching  in  the  back  is  felt.  At  the  same  time  disturbances  in  the 
kidney  (Head)  zones  may  become  prominent,  so  that  in  many  cases 
they  are  a  sign  of  value.  Should  the  disease  still  further  progress 
and  become  extracapsular,  tenderness  to  pressure  is  excessive; 
breathing  becomes  difficult,  and  motion  of  all  kinds  is  greatly 
limited.  At  this  time  a  perinephritis  may  develop.  Urination 
becomes  painful  and  frequent,  and  pain  is  referred  to  the  glans 
penis  and  down  the  thigh  (p.  609).  The  patient  walks  or  re- 
clines with  the  body  bent  toward  the  affected  side,  and  in  many 
cases  the  thighs  slightly  flexed  on  the  abdomen.  .  Pain  may  also  be 
present  on  pressure  anteriorly  over  the  abdomen,  and  posteriorly 
over  the  flank ;  in  some  cases  the  anterior  pressure  may  cause  pain 
and  the  posterior  pressure  may  give  relief. 


DIAGNOSIS    OF    KIDNEr   DISEASES    CAUSING   PAIN      653 

Symptoms  associated  with  a  pyonephrosis  are: 

(1)  The  presence  of  pus  in  the  urine.  It  may  be  present  only 
occasionally  in  intermittent  pyonephrosis,  being  absent  at  the 
time  the  ureter  from  the  diseased  kidney  is  blocked,  but  appearing 
again  as  soon  as  the  obstruction  is  removed.  Its  reappearance  is 
concomitant  with  a  gi-eatly  increased  urinary  flow.  Pyelonephritis 
can  often  be  diagnosed  by  the  presence  in  the  urine  of  casts  com- 
posed of  pus  cells.  It  may  be  distinguished  from  pyonephrosis 
in  that  in  the  latter  condition  cellular  casts  are  absent  and  large 
quantities  of  urine  and  pus  are  passed  at  intervals,  at  which  time 
the  symptoms  referable  to  obstruction  are  relieved. 

(2)  Chills  and  fever,  usually  associated  with  a  septic  infec- 
tion, are  present. 

Hydronephrosis. — Causes. — Hydronephrosis  is  due  to  an  ob- 
struction of  the  ureter.  It  is  of  two  types,  constant  and  intermit- 
tent. Constant  hydronephrosis  is  the  result  of  forces  acting  con- 
stantly. Intermittent  hydronephrosis  is  the  result  of  some  cause 
acting  intermittently,  and  is  due  to  the  blocking  of  the  ureter  by  a 
stone,  blood  clot,  or  piece  of  necrotic  tissue. 

Character  of  the  Pain. — Pain  in  hydronephrosis  is  not  marked, 
except  when  the  intranephritic  tension  is  suddenly  raised.  Should 
the  obstruction  be  complete  pain  at  first  is  very  severe,  then  gradu- 
ally ceases,  because,  as  a  rule,  under  such  circumstances  the  secre- 
tion of  urine  soon  ceases  and  pelvic  distention  does  not  persist. 
The  pain  in  the  majority  of  cases  of  hydronephrosis  is  of  a  drag- 
ging or  dull  aching  type,  and  may  be  continuous  or  intermittent. 
The  intermittency  indicates  that  the  ureteral  obstruction  is  not 
complete,  and  that  at  times  there  occurs  a  partial  relief  of  the 
pressure  from  some  of  the  urine  being  forced  through  the  semi- 
patulent  canal. 

Sudden  and  severe  pain  may  occur  if  the  hydronephritic  sac 
should  rupture  into  the  abdominal  cavity.  Peritonitis  then  results 
and  the  pain  assumes  the  character  of  the  pain  associated  with 
that  condition.  It  may  radiate  to  the  back  above  the  pelvic  brim, 
or  around  the  side  to  the  external  genitals. 
.   Sudden  subsidence   of  the   pain  in  hydronephrosis   indicates 


654  THE    KIDNEY 

that  the  obstruction  to  the  onward  flow  of  urine  has  been  removed, 
either  because  it  has  been  forced  into  the  bladder,  or  because  the 
material  (calculus)  which  was  acting  as  a  valve  at  the  entrance 
of  the  ureter  has  been  forced  back  into  the  pelvis  of  the  kidney, 
thus  allowing  the  passage  to  be  free  (ball-valve  action). 

Associated  Symptoms. — Associated  signs  of  hydronephrosis 
are:  (1)  the  presence  of  a  tumor,  located  below  the  costal  margin. 
It  is  round,  smooth,  or  lobulated.  The  colon  is  anterior  to  it  or 
is  on  its  inner  side ;  in  this  particular  a  tumor  or  enlargement  of 
the  kidney  differs  from  that  of  the  gall  bladder,  intestine,  omen- 
tum, or  appendix,  which  are  generally  anterior  to  the  colon. 

(2)  Xausea  and  vomiting  are  very  common  in  the  cases  of 
acute  hydronephrosis. 

Points  that  lead  to  an  almost  positive  diagnosis  of  hydro- 
nephrosis are:  (a)  the  presence  of  a  dragging  pain  in  the  back, 
(b)  a  tumor  mass  in  the  kidney  region,  and  (c)  a  decrease  or 
increase  in  size  of  this  tumor  mass,  occurring  simultaneously 
with  an  increase  or  decrease  in  the  amount  of  the  urine,  (d)  ure- 
teral catheterization  and  distention  of  the  renal  pelvis  by  meas- 
ured quantities  of  salt  solution,  (e)  injection  of  collargol  into  the 
renal  pelvis,  and  then  a  Roentgen  picture  (these  will  clearly  indi- 
cate the  lesion). 

Hydronephrosis  in  Pregnancy. — During  pregnancy  the  uterus, 
because  of  unilateral  enlargement,  or  because  of  its  peculiar  posi- 
tion in  the  pelvis,  may  make  more  pressure  upon  one  than  upon 
the  other  ureter.  The  consequence  is  that,  if  the  pressure  is  great 
enough,  a  unilateral  hydronephrosis  results.  This  causes  consid- 
erable annoyance  to  the  patient  and  much  anxiety  to  the  attending 
physician,  for,  when  the  stasis  occurs,  violent  pain,  due  to  the  in- 
creased tension  in  the  pelvis  of  the  affected  kidney,  is  produced. 
Because  of  slight  temperature,  the  presence  of  pus  in  the  urine, 
the  appearance  of  a  mass  which  is  tender  in  the  lumboiliac  re- 
gion, and  the  constant  complaint  of  the  patient,  a  condition  of 
this  kind  sometimes  is  mistaken  for  a  lumbar  or  perinephritic  ab- 
scess; yet  the  normal  leukocyte  count,  the  marked  remission  fol- 
lowing a  copious  discharge  of  urine,  the  low  position  of  the  uterus, 


DIAGNOSIS    OF    KIDKEY   DISEASES    CAUSING   PAIN      655 

the  relief  which  sometimes  follows  the  assumption  of  the  abdom- 
inal prone  position,  and  the  late  stage  of  pregnancy,  all  point  to 
a  pressure  hydronephrosis  with  a  slight  infection.  After  deliv- 
ery the  condition  passes  off  without  any  permanent  ill  results, 

A  case  illustrative  of  this  condition  is  that  of  Mrs.  M , 

eight  months  pregnant,  who  at  times  would  have  severe  pain  on 
the  right  side  in  the  kidney  region.  The  pain  would  be  accom- 
panied by  a  lumbar  enlargement  on  the  same  side.  The  pain  and 
enlargement  would  both  disappear  synchronously  with  the  ap- 
pearance in  the  urine  of  a  considerable  number  of  pus  cells.  At 
the  same  time  the  quantity  of  urine  would  be  greatly  increased. 
After  delivery  all  the  symptoms  disappeared. 

Renal  Calculus. — Renal  calculi  may  lie  in  the  pelvis  of  the 
kidney  for  many  years  without  producing  symptoms.  Several 
cases  have  been  reported  where  stones  weighing  as  much  as  one 
ounce  have  remained  quiescent  in  the  kidney  for  long  periods  of 
time.  In  one  case  the  presence  of  the  stone  was  entirely  unknown 
to  the  patient  until  an  abscess  formed  and  ruptured  posteriorly. 
If  these  stones  do  not  at  times  produce  symptoms  it  is  necessary 
to  know  what  must  occur  before  their  presence  becomes  so  intoler- 
able as  to  draw  attention  to  them. 

Etiology  of  Calculus  Pain. — From  a  long  series  of  observa- 
tions it  has  been  concluded  that  renal  calculi  do  not  produce  pain 
symptoms  unless  a  blocking  of  the  ureter  occurs. 

For  a  long  time  and  by  many  observers  it  has  been  held  that 
a  spasm  of  the  ureter  is  the  cause  of  pain  in  calculus  colic,  and  ic 
has  only  recently  been  determined  that  the  pain  of  renal  calculus 
is  not  due  to  spasm  of  the  ureter,  but  is  caused  by  tension  on  the 
renal  capsule  from  back  pressure  of  the  urine.  Many  cases  con- 
firmative of  this  could  be  cited,  but  Bevan's  case,  which  is  de- 
scribed on  page  605,  will  illustrate  the  point  exactly.  Fenwick, 
in  1893,  was  one  of  the  first  to  suggest  this  explanation  of  a 
calculus  colic. 

That  the  distention  of  the  ureter  is  not  the  only  cause  of  renal 
calculus  pain,  and  that  the  ureter  itself  has  some  place  in  the 
pain  production,  is  seen  in  the  changing  position  of  the  pain  as  the 


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Pain    is    in    the    gall-bladder 
areas  (q.  v.).     This  pain  can 
be  produced  by  pressure  on  or 
by  traction  dragging  on  the 
tumor  mass. 

Is  on  the  right  side.  Rotates 
around  a  center  located  near 
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costal  cartilage. 

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Constant  where  the  ureteral 
obstruction  is  permanent.  In- 
termittent where  the  ureteral 
obstruction  is  irregular. 

Is  to  one  side  of  the  vertebral 
column,  and  extends  laterally 
into  the  lumbar  region. 

Lies    in    front    of    a    hydro- 
nephrosis, though  in  those  of 
very   large  size  it  may  lie  to 
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DIAGNOSIS    OF   KIDNEY   DISEASES    CAUSING   PAIN     657 

stone  gradually  progresses  downward  toward  the  bladder.  The 
cause  of  this  changing  pain  is  the  progressive  distention  of  the 
ureter  proximal  to  the  stone,  for,  as  the  stone  advances,  the  dila- 
tation progresses  downward  and  the  pain  likewise  becomes  lower 
until  it  merges  into  that  due  to  bladder  involvement.  The  reason 
that  the  passage  of  some  calculi  is  painful  and  that  of  others  is 
not  is  that  those  which  are  not  painful  as  a  rule  are  small,  and 
do  not  block  the  ureter  to  as  great  a  degree  as  do  the  larger  ones. 
A  stone  that  is  sharp  also  may  cause  considerable  irritation  and 
consequent  inflammation  of  the  mucous  membrane,  and  thus 
block  the  ureter,  and  give  rise  to  greater  pain  than  a  smooth  stone 
of  much  larger  diameter.  Oxalate  of  lime  calculi  are  rough,  hard, 
spiculated,  and  nodulated,  and  are  more  painful  than  the  uric 
acid  stones,  which  are  smooth. 

The  blocking  of  the  ureter  may  be  due  to  the  calculus  itself 
or  may  be  the  result  of  the  lodgment  in  the  ureter  of  clots  or  of 
fragments  of  debris,  the  consequence  either  of  hemorrhage  or  of 
infection  secondary  to  the  calculus  formation.  If  the  obstruc- 
tion of  the  ureter  is  acute  and  complete,  pain,  which  at  first  was 
a  prominent  symptom,  gradually  becomes  less  marked  and  finally 
disappears.  This  disappearance  is  accounted  for  by  the  slowly 
progressive  decrease  in  the  urinary  secretion,  so  that  the  pressure 
in  the  renal  pelvis,  which  at  first  was  excessive,  becomes  less  and 
less,  and  finally  is  entirely  absent.  If  in  any  stage  of  this  process 
the  back  pressure  urine  should  be  infected,  or  should  infection 
occur  later,  when  the  fluid  in  the  renal  pelvis  has  been  absorbed, 
a  new  factor  in  the  pain  production  makes  its  appearance.  For 
this  infection  causes  irritation  to  the  kidney  cells,  pus  again 
accumulates  in  the  renal  pelvis,  pressure  is  again  exerted,  and 
pain  once  more  appears. 

This  secondary  fain  is  of  a  serious  prognostic  import.  It  tells 
the  tale  of  progressive  kidney  disaster,  for  as  soon  as  pus  invades 
the  parenchyma  of  the  kidney,  and  a  kidney  abscess  with  marked 
sensory  disturbances  in  Head  zones  appears,  it  indicates  further 
spread  of  the  infection,  on  its  evil  march  of  progress.  It  now  soon 
extends  to  the  perirenal  tissues,  and  forms  a  perirenal  abscess. 


658  THE   KIDNEY 

From  this  arises  the  last  set  of  symptoms  of  this  grave  disorder. 
For  a  description  of  these  symptoms  see  Perinephritis. 

Character  of  Calculus  Pain. — In  nearly  every  case  of  renal 
calculus  pain  is  present  at  some  time  in  its  course.  This  pain  may 
be  either  constant  or  paroxysmal.  The  more  or  less  constant  pain 
is  present  when  the  stone  is  in  the  renal  pelvis  and  is  too  large 
to  enter  the  ureter.  Because  of  its  position  it  may  have  a  ball- 
valve  action,  and  unless  the  inflammation  is  more  or  less  severe, 
the  pain  is  not  constant,  so  that  when  the  pain  does  become  con- 
stant it  indicates  that  inflammation  of  the  renal  pelvis  has  oc- 
curred. 

The  i)aroxysmal  pain  complained  of,  as  a  rule,  is  very  sudden 
in  onset  and  is  unilateral.  It  is  mostly  on  the  side  of  the  affected 
kidney,  but  has  been  known  to  be  present  on  the  opposite  side 
(reno-renal  reflex).  It  is  present  in  half  the  cases  of  renal  cal- 
culi, and  is  of  the  greatest  severity.  In  fact,  it  may  be  so  severe 
that  the  patient,  under  its  influence,  becomes  irrational  and  de- 
moniacal. 

At  first  it  is  more  of  an  intermittent  or  constant  aching  or 
dragging  in  the  small  of  the  back.  This  at  times  is  interrupted 
and  aggravated  by  twitches  of  pain,  until  suddenly  some  day  an 
attack  of  the  greatest  intensity  occurs.  The  pain  now  switches 
from  the  back,  and  may  run  around  the  crest  of  the  ilium  to  the 
anterior  abdominal  wall,  and  be  located  beneath  the  ribs  or  in  the 
iliac  region.  It  may  also  be  felt  in  the  gToin  or  in  the  tes- 
ticle of  the  affected  side,  following  the  course  of  the  genito- 
crural,  the  ilioinguinal  and  the  iliohypogastric  nerves.  It  may 
even  be  felt  in  the  leg  in  the  course  of  the  lumbar  nerves,  and, 
though  it  may  go  as  far  as  the  toe  (anterior-crural),  it  rarely 
runs  farther  than  the  knees.  The  testicle  during  an  attack  is  pain- 
ful and  sore.  It  is  said  by  Head  that  retraction  of  the  testicle 
takes  place  as  soon  as  the  stone  reaches  a  point  above  the  pelvis. 
The  scrotum  is  not  affected.  The  reason  of  this  is  that  originally 
the  testicle  was  an  intraabdominal  organ,  arising  at  about  the  same 
visceral  level  as  the  kidney.  It  gradual!}^  became  more  and  more 
displaced  downward,  until  it  reached  its  present  position.     As  it 


DIAGNOSIS    OF    KIDNEY   DISEASES    CAUSING   PAIN     659 

descended  it  carried  with  it  some  of  its  coverings  and  its  own 
nerve  supply;  this  nerve  supply  arises  from  the  same  cord  seg- 
ment as  do  the  nerves  supplying  the  kidney  and  upper  part  of 
the  ureter.  Consequently  any  lesion  in  the  kidney  may  reflexly 
cause  pain  to  be  experienced  in  the  testicle.  The  scrotum  is  not 
affected  because  it  derives  its  nervous  supply  from  a  different  set 
of  nerves  which  are  not  in  any  way  intimately  related  to  those 
supplying  the  kidney  or  ureter. 

Duration  of  the  Attack. — The  duration  of  the  attack  is  vari- 
able. It  may  last  only  for  a  few  minutes  or  for  as  many  hours. 
Generally  it  lasts  until  the  stone  has  either  been  forced  back  into 
the  kidney  pelvis,  has  entered  the  bladder,  or  until  dilatation  of 
the  ureter  has  taken  place,  so  that  the  urine  can  pass  around  the 
stone.  As  the  stone  approaches  the  bladder,  frequent  and  painful 
urination  occurs.  When  the  condition  has  persisted  for  some 
days  exacerbations  of  pain  are  frequent  at  night,  and  are  probably 
due  to  pressure  on  the  kidney  by  gas  passing  down  the  bowel 
(Jackson).  Attacks  of  pain  may  at  times  be  caused  by  an  over- 
loaded colon.  They  may  also  occur  spontaneously  or  be  due  to 
mechanical  means,  such  as  jarring  or  vibratory  movements.  Ma- 
nipulation of  the  kidney  also  incites  an  attack.  Sudden  cessation 
of  the  pain  generally  indicates  that  the  stone  has  passed  through 
the  ureter  into  the  bladder. 

Location  of  the  Pain. — In  renal  calculus  there  are  three  va- 
rieties of  pain:  (1)  local  pain,  (2)  referred  pain,  and  (3)  re- 
flected pain. 

In  the  renal  calculus  disorders,  the  local  pain,  as  a  factor  in 
diagnosis,  can  practically  be  disregarded.  It  is  not  present, 
except  in  the  form  of  tenderness,  which  will  be  considered  later. 

Referred  pain  is  the  name  given  to  the  pain  which  is  trans- 
mitted along  the  course  of  the  spinal  nerves  from  an  irritation 
on  one  of  their  branches.  Here  is,  indeed,  a  hornet's  nest,  for  it 
is  almost  impossible,  in  this  connection,  to  differentiate  the  re- 
ferred from  the  reflected  pains,  inasmuch  as  both  are  transmitted 
along  the  same  nerve  fibers,  though  each  has  a  slightly  different 


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DIAGNOSIS    OF    KIDNEY   DISEASES    CAUSING   PAIN     661 


distribution  area.     Yet  it  is  not  of  absolute  importance,  as  far  as 
diagnosis  is  concerned,  to  differentiate  between  the  two. 

Below  will  be  shown  the  distribution  area  of  the  spinal 
nerves,  and  at  the  same  time  the  distribution  area  of  the  zones 
of  Head,  which  represent  the  reflected  pain.  The  reno-renal  re- 
flex also  represents  a  reflected  pain. 


Fig.  152. — Head  Zones  of  Hyper- 
algesia Usually  Associated 
WITH  Kidney  Lesions:  An- 
terior View. 


Fig.  153. — Head  Zones  of  Hyper- 
algesia Usually  Associated 
WITH  Kidney  Lesions:  Pos- 
terior View. 


Figures  150  and  151  show  the  areas  of  distribution  of  the  cere- 
brospinal nerves,  figures  152  and  153  show  the  area  of  distribution 
of  the  cord  zones. 

From  the  accompanying  figures  it  may  be  seen  how  closely  the 
distribution  of  the  spinal  zones  corresponds  with  the  distribution 
area  of  the  spinal  nerves.  As  the  calculus  progTesses  down  the 
ureter,  these  areas  of  hyperalgesia  extend  lower  and  lower  (from 
the  tenth  dorsal  to  the  first  lumbar),  so  that  in  some  cases  the 
progi'ess  of  the  stone  may  be  defined  by  the  progressively  lower 
location  of  the  hyperalgesic  areas.  The  circles  which  are  shaded 
indicate  the  maximal  points  of  tenderness  of  the  respective  zones. 
When  the  colic  comes  on  and  ureteral  dilatation  occurs,  these 


662 


THE   KIDNEY 


areas  of  maximal  pain  are  most  exquisitely  tender,  and  by  the 
uninitiated  are  often  mistaken  for  tenderness  in  an  nuderlyino; 
organ. 

The  following  drawing  is  from  Head,  and  the  accompanying 
legend  will  sufficiently  explain  it. 

Reno-renal  Reflex. — In  some  cases  of  renal  calculus  the  pain 
may  be  reflected  entirely  to  the  opposite  side.     Although  there  has 


J' 

Very  tender  spots 


-  Very  tender  spot 


Maximal  point  of 
tenderness  of  10th 
and  lltli  dorsal 


Area  of  distribution  of  10th, 
11th  and     12th  dorsal 


Fig.  154. — Area  of  Cutaneous  Hyperalgesia  in  Severe  Renal  Colic 
IN  WHICH  THE  Stone  WAS  IN  THE  Ureter.  "The  pain  starts  behind 
at  the  tip  of  the  twelfth  rib  and  runs  forward  to  a  point  in  the  left 
Uiac  fossa,  thence  to  a  point  above  the  internal  ring,  then  to  the 
pubes,  and  thence  to  the  inner  aspect  of  thigh  where  it  ends  just  above 
the  knee."     (Head,  Brain,  Vol.  XVI,  p.  76.) 


been  much  controversy  in  regard  to  this  condition,  there  can  be 
no  doubt  that  this  so-called  reno-renal  reflex  is  occasionally  present. 
In  it  pain  may  apparently  be  associated  with  one  kidney  which  is 
entirely  healthy,  while  the  other  kidney  is  diseased.  Mr.  Morris 
does  not  believe  in  its  presence,  and  in  his  work,  "Surgical  Dis- 
eases of  the  Kidney  and  Ureter,"  says  that  "this  theory  is  un- 
sound and  dangerous  if  acted  upon" ;  but  Maylard  quotes  a  case 
of  his  own,  confirmative  of  it,  namely:  A  man,  aged  28,  com- 
plained of  a  "nagging  pain  in  the  right  iliac  region,  which 
seemed  to  him  to  pass  upward  and  lodge  in  the  right  iliac  lumbar 


DIAGNOSIS    OF   KIDNEY   DISEASES    CAUSING   PAIN      663 

region,  where  it  produced  a  dull,  sickening  sensation.  It  "vvoulJ 
linger  tliere  for  twenty -four  hours,  during  which  time  he  would 
vomit.  Urine,  after  one  of  these  attacks,  contained  albumin  and 
red  blood  cells,  but  not  tube  casts.  Mavlard  explored  the  right 
kidney  and  passed  a  catheter  down  the  right  ureter,  but  nothing 
could  be  detected.  Suppression  of  urine  developed  immediately 
after  operation,  and  the  patient  died  on  the  fourth  da}'.  On  post 
mortem  the  right  kidney  was  perfectly  healthy,  but  the  left  one  eon- 


FiG.  155. — Pressure  Made  upon  Ureter  in  Endeavor  to  Obtain  Local 
Tenderness.  The  pressure  is  made  directly  over  the  region  where  the 
ureter  passes  over  the  pelvic  brim  and  enters  the  cavity  of  the  pelvis. 


tained  in  one  of  the  upper  calices  a  calculus  about  as  large  as  a 
pea."  (Maylard,  "Abdominal  Pain,"  p.  101.)  Other  cases,  too 
numerous  to  mention,  confirmative  of  this  condition  could  be 
cited.  Prout,  in  1840,  was  probably  the  first  to  draw  attention 
to  this  reflex. 

Therefore,  in  all  kidney  cases  it  is  most  necessary,  in  order 
that  mistakes  may  not  be  made,  that  this  peculiar  and  unusual 
transference  of  the  symptoms  be  considered.  Many  a  tragedy  of 
surgery  has  occurred  because  the  surgeon  was  ignorant  of  this 
phenomenon.  Its  manner  of  occurrence  is  explained  under  the 
description  of  the  reflection  of  kidney  pain.  In  all  cases  of  sus- 
pected kidney  disorder  the  attending  physician  and,  most  of  all, 
the  surgeon,  should  not  rely  too  much  upon  the  character  of  the 


664 


THE   KIDNEY 


sjmptoms  to  define  the  kidney  affected.  In  every  case  one  always 
has  the  ureteral  catheter  with  which  to  collect  a  little  urine,  and 
thus  possesses  the  means  definitely  to  localize  the  lesion. 

At  times  it  is  very  difficult,  from  the  pain  phenomena  alone, 
to  localize  the  stone  to  a  certain  definite  part  of  the  ureter,  for 
occasionally  a  stone  in  the  lower  end  of  the  ureter  will  produce 
I^ain  in  the  kidney  area,  while  one  in  the  upper  part  of  the  ureter 
or  in  the  pelvis  of  the  kidney  will  produce  pain  along  the  entire 
distribution  area  of  the  zones  associated  with  the  ureter. 


^  Tournier's  points 


Fig.   156. — Touknier's  Points   of  Pressure  in  Kidney  and  Ureter 

Lesions. 

Tenderness. — Tenderness  is  always  present  in  calculus  disease. 
It  may  be  of  the  superficial  type  found  in  the  maximal  points  of 
tenderness  of  the  Head  zones,  or  it  may  be  tlie  local  tenderness 
found  over  the  affected  kidney  (anterior  or  posterior)  or  along 
the  course  of  the  ureter. 

The  upper  part  of  the  ureter  and  the  lower  extremity  of  the 
kidney  approximately  may  be  reached  by  pressure  at  the  level  of 
a  point  described  by  Tournicr  as  being  "situated  at  the  intersec- 
tion of  a  transverse  line  drawn  between  the  tips  of  the  twelfth 
ribs  with  that  of  a  vertical  line  drawn  upward  from  the  junction 
of  the  inner  and  middle  thirds  of  Poupart's  ligament." 

Tenderness   at  this   point  indicates   a  painful  lesion   of  the 


DIAGNOSIS    OF    KIDNEY    DISEASES    CAUSING    PAIN    665 

ureter,  such  as  is  produced  by  ureteritis,  tuberculosis,  or  calculus. 
The  intersection  of  a  line  drawn  between  the  two  iliac  spines  with 
one  that  is  drawn  vertically  through  the  spines  of  the  os  pubis  ap- 
proximately indicates  the  point  at  which  the  ureter  passes  over 
the  pelvic  brim.  Because  of  the  narrowed  lumen  of  the  ureter  at 
this  point  a  calculus  frequently  lodges  here  and  causes  pain. 

Palpation  of  the  ureter  is  not  very  satisfactory.  In  men  it 
may  be  palpated  for  one  or  two  inches  above  the  bladder  by  a 
rectal  examination,  while  in  Avomen,  by  a  vaginal  examination,  it 
may  be  palpated  for  two  or  three  inches  above  its  vesical  insertion. 
In  this  lower  accessible  portion,  therefore,  local  tenderness  in 
cases  of  stone  or  inflammation  may  be  elicited  by  palpation.  The 
great  difficulty  in  drawing  conclusions  from  tenderness  located  in 
this  region  is  that  it  is  almost  impossible  to  say  with  any  degi'ee 
of  positiveness  whether  the  tenderness  which  is  present  is  due  to 
ureteral  involvement  alone  or  is  the  result  of  some  disease  of  the 
adjacent  structures. 

Factors  Influencing  the  Pain. — The  factors  influencing  the 
painful  attacks  are: 

(1)  The  Position  of  the  Patient. — Change  of  position  some- 
times causes  pain,  and  certain  positions  are  productive  of  more 
pain  than  are  others.  These  positions  are  generally  the  ones  in 
which  the  stone,  if  present  in  the  kidney,  would  have  a  tendency 
to  gravitate  to  and  block  up  the  outlet  of  the  renal  pelvis.  In 
these  cases  the  pain  is  the  result  of  pelvic  distention.  Reversal 
of  the  position  which  produced  the  pain  generally  eases  it,  and 
may  even  cause  it  to  disappear  entirely,  the  disappearance  being 
followed  by  a  considerable  increase  in  the  flow  of  urine.  Should 
the  stone  be  in  the  ureter  change  of  position  would  not  produce 
any  special  diiference  in  the  amount  of  pain  produced  unless  the 
changed  position  should  cause  pressure,  pulling  or  dragging  upon 
the  ureter  by  some  of  the  adjacent  organs. 

On  the  other  hand,  should  the  kidney  be  movable,  and  dis- 
placement occur,  it  is  easy  to  conceive  how,  in  the  dropping  or 
in  the  turning  of  the  kidney  from  the  displacement,  a  kink  or  a 
twist  may  occur  in  the  ureter,  and  how  this,  by  causing  renal 


666  THE    KIDNEY 

distention,  may  act  as  a  pain-producing  factor.  Under  these  cir- 
cumstances a  replacement  of  the  kidney  into  its  normal  location 
will  relieve  the  pain. 

The  patient,  during  an  attack  of  renal  colic,  generally  lies  all 
bent  up.  At  the  same  time  he,  as  a  rule,  presses  his  hand  into 
the  abdomen,  and  this  seems  to  ease  the  pain.  In  this,  renal 
colic  is  not  different  from  other  colics,  for  all  are  to  some  extent 
relieved  by  pressure.  Patients  affected  with  kidney  calculus  walk 
with  the  hand  so  placed  over  the  affected  side  that  the  thumb 
presses  on  the  loins  behind  and  the  fingers  on  the  iliac  fossa  in 
front.     (See  Figure  142,  p.  617.) 

(2)  Motion. — lu  those  who  have  kidney  stones  motion  often 
incites  an  attack,  especially  so  when  the  motion  is  similar  to  that 
which  occurs  in  riding  over  rough  roads  in  a  badly  constructed 
carriage,  or  in  vehicles  in  which  there  is  considerable  jolting,  that 
is,  one  may  say,  shaking  motion.  Lifting,  sudden,  sharp  turning, 
as  in  tenuis  playing,  throwing,  running  or  jumping,  all  seem  to 
initiate  an  attack.  Bending  forward  or  backward  is  apt  to  cause 
its  appearance,  or  to  increase  it  if  it  is  already  present. 

(3)  Digestion  seems  to  be  especially  potent  in  causing  pain 
in  renal  calculus.  This  is  probably  due  to  two  causes:  (a)  the 
changing  relationships  of  the  bowel  during  digestion  cause  it  to 
press  upon  the  kidney  and  thus  produce  pain,  and  (b)  the  dis- 
turbed digestive  powers  of  the  alimentary  tract  may  cause  some 
substances  to  be  absorbed,  which,  on  being  eliminated,  increase 
the  irritability  of  the  urine  and  give  rise  to  pain  as  they  pass 
over  the  sensitive  mucous  membrane  lining  of  the  kidney  and 
ureter. 

(4)  Manipulation  of  the  kidney  frequently  incites  an  attack 
of  renal  colic. 

Associated  Symptoms. — Symptoms  associated  with  the  passage 
of  a  renal  calculus  are: 

(1)  Frequency  of  Micturition. — This  becomes  more  annoying 
the  nearer  the  stone  is  to  the  bladder  until,  when  it  is  just  ex- 
ternal to  the  bladder,  the  desire  to  urinate  is  almost  constant. 
According  to  Schmidt,  the  opposite  holds  true  in  tuberculosis  of 


DIAGNOSIS    OF    KIDNEY   DISEASES    CAUSING   PAIN     667 

the  kidney  without  a  cystitis,  and  in  kidney  infarct,  when  the 
desire  to  urinate  almost  entirely  disappears. 

(2)  Increased  Blood  Pressure. — The  blood  pressure  is  greatly 
increased  at  the  time  of  the  attack,  but  this  is  only  a  vasomotor 
reflex  incited  by  the  pain  sensation.  It  is  nothing  more  than  the 
usual  reflex  associated  with  all  severe  pain.  It  but  confirms  the 
patient's  statements  that  pain  is  present. 

(3)  Swelling  and  sensitiveness  of  the  urethra  may  precede 
an  attack. 

(4)  Digestive  Symptoms. — Kausea  may  be  present  and  vomit- 
ing is  very  common.  Both  may  be  present  without  the  pain.  They 
are  due  to  the  close  association  of  the  kidney,  intestines,  and 
stomach,  through  the  abdominal  sympathetic.  These  digestive  dis- 
orders, when  severe,  may  lead  to  error  in  diag-nosis,  especially  so 
when  constipation  is  present. 

(5)  Changes  in  the  Urine. —  (a)  Blood  as  a  rule  is  present. 
It  follows  an  attack  of  colic.  While  appreciable  microscopically, 
as  a  rule  it  is  not  in  any  very  gi-eat  quantity,  (b)  Various  uri- 
nary salts,  as  phosphates,  urates,  oxalates,  are  present  in  abnormal 
amounts,  (c)  Albumin  may  be  found,  (d)  The  sign  of  great 
value  is  the  absence  of  the  normal  urinary  flow  from  the  ureter 
on  the  affected  side.  This  can  best  be  demonstrated  by  the  use 
of  the  cystoscope  and  ureteral  catheter. 

(6)  Subjective  sensations  of  cold  in  the  thigh  of  the  affected 
side  are  sometimes  present  (Schmidt). 

(T)  Chills  are  very  frequent,  especially  when  Dietl's  crisis 
is  present. 

(8)  Spasms  in  the  muscles  of  the  calf  or  thigh  of  the  same 
side  may  be  present  (see  Innervation). 

(9)  Collapse  may  occur  at  the  time  of  the  greatest  severity 
of  the  renal  pain. 

(10)  Elevation  of  temperature  is  frequent  at  the  time  of  the 
attack. 

(11)  Renal  Stones. — The  X-ray,  as  a  rule,  shows  a  renal 
stone. 

In  many  instances,  while  the  colic  may  indirectly  be  due  to 


668  THE    KIDNEY 

calculus  formation,  it  is  not  directly  so  produced ;  for  instead  of  a 
calculus  the  obstruction  to  the  ureter  has  in  many  instances  been 
found  to  be  pieces  of  blood  clot,  etc.  Generally  they  are  the 
result  of  a  secondary  infection. 

Dijfercntial  Diagnosis. — The  diagnosis  of  a  renal  calculus 
should  be  made  from  tuberculous  kidney,  new  growth  of  the  kid- 
ney with  hemorrhage  into  the  substance,  and  kinks  of  the  ureter. 
In  renal  calculus  the  colic  is  sometimes  mistaken  for  that  of 
intestinal  obstruction,  chiefly  on  account  of  the  intestinal  disten- 
tion and  the  inability  to  move  the  bowels.  These  latter  are  fre- 
quently the  result  of  the  large  doses  of  morphin  which  have  been 
given  to  the  patient.  Ureteral  colic  on  the  right  side  is  often 
confused  with  appendicitis. 


2 

« 
X 

H 

Generally   rather   severe 
at  first.  A  general  aching, 
and   tenderness   to   deep 
pressure.        Then,  later, 
there  is  present  a  tumor 
with  great  pain  and  ex- 
cessive tenderness. 

May   be   no   very   great 
change  in  the  character 
of  the  urine,  though,  as  a 
rule,    some   red   cells    or 
leukocytes  are  found. 

a 

03 

>, 
"oi 

3 
O 

Tumor  present  some  time 
after  the  development  of 
the  pain.     Size  of  tumor 
not    affected    by    renal 
catheterization. 

Very  tender. 

CO 

o 

There  may  be  no  pain  as  long 
as  the  calculi  remain  in  the 
pelvis  of  the  kidney.     Pain  is 
felt  only  when  the  stone  passes 
into  the  ureter.     Then  symp- 
toms of  ureteral  colic,  sudden, 
sharp,  paroxysmal,  agonizing 
pains  occur.     The  pain  is  the 
most  severe  to  which  man  is 
heir.     The  severity  is  due  to 
the|  very    sharp  and    jagged 
character  of  the  calculus. 

Generally  a  diminution  at  the 
time  of  the  cohc  followed  by 
a  sudden  increase  on  the  re- 
lief of  the  cohc. 

3 

03 

g 

Tumor  may  or  may  not  be 
present.     When  it  is  present, 
it  is  due  to  a  hydronephrosis. 
Passage  of  a  wax-tipped  cath- 
eter shows  location  of  stone. 
Idem. 

M 

M 
O 

w 

» 
z 
o 

PS 
Q 

Considerable  pain  is  pres- 
ent, especially  so  if  the  con- 
dition is  one  of  acute  origin. 
Generally  the  pain  felt  is 
due  to  the  original  cause  of 
the  disease. 

Generally  but  slightly 
changed.        Blood    is    fre- 
quently  profuse    after   re- 
lief of  the  occlusion. 
Sudden     increase     in     the 
quantity  of  the  urine  causes 
a  diminution  in  the  size  of 
the  tumor. 

.2, 

'c? 

a 

a 

Immediate  formation.    De- 
creased in  size  on  ureteral 
catheterization  of  the  pel- 
vis.    Tumor    can    be  pro- 
duced at  will  by  fiUingthepel- 
vis  of  the  kidney  with  fluid. 
Idem. 

H 

Generally  very  little  in  the 
early  stages,  and  the  pain 
that  is  present  is  due  to  a 
nephrectasis  or  to  a  spread- 
ing of  the  disease  to  such  an 
extent  that  either  the  entire 
parenchyma    or    the    peri- 
nephritic  tissues  have  be- 
come involved. 

Generally  turbid.     Specific 
gravity  is  low.      Blood  fre- 
quent though  not  profuse. 
T.    B.    are   present   in   the 
centrifugaUzed  urine.      In- 
oculation   produces    death 
in  the  guinea  pig. 

Generally  not  present  un- 
less    secondary     infection, 
with    pus-forming    bacilli, 
occurs. 

Early  formation.  On  cath- 
eterization,  no    noticeable 
difference    in     size   of    the 
tumor  mass  may  be  found. 

Tumor  not  tender. 

CQ 

Hi 

a 

r/2 

a 

Pu, 

0 

i 

Tumor  and   catheter- 
ization and  tender- 
ness. 

669 


CHAPTEE  XXX 

THE  UEETEE,  BLADDER  AND  URETHEA 

THE   URETER 

Pain  associated  with,  ureteral  involvement  is  due  to : 

(1)  Obstruction  of  the  ureter.  This  is  caused  by  muscular 
spasm,  which  produces  (a)  hydronephrosis,  in  which  there  is  gen- 
erally a  certain  amount  of  associated  infection,  and  (b)  dilata- 
tion of  the  ureter.  Obstruction  may  also  be  caused  by  calculus, 
blood  clots,  detritus,  kinks,  external  pressure  from  tumors  (aortic 
aneurysm)  or  growths  in  adjacent  organs  (as  carcinoma  of  the 
bladder  at  the  point  of  ureteral  insertion),  displacement  of  adja- 
cent organs  (making  pressure  on  the  ureter),  and  stenosis  of  the 
ureter,  which  may  be  intralumenary  from  stricture,  or  extralume- 
nary  from  inflammation  of  the  walls  or  of  the  surrounding  tissues. 

(2)  Inflammation  (ureteritis)  may  also  cause  pain  in  ureteral 
disease. 

Obstruction  to  the  ureter  produces  at  first  a  muscular  spasm 
and  then  a  distention  of  the  proximal  ureter  and  renal  pelvis. 
This  causes  a  sudden  sharp  pain.  To  what  extent  the  ureters  are 
innervated  by  the  cerebrospinal  system  is  still  a  question  for  the 
physiologists,  but  it  has  been  shown  that  the  mucous  and  muscular 
coats  are  innervated  by  both  medullated  and  non-medullated  nerves, 
so  that  the  spasm,  which  is  produced  by  an  irritating  stone,  would 
affect  both  cerebrospinal  and  sympathetic  nerves,  and  thus  cause 
both  local  and  reflected  pain.  The  local  pain  is  due  to  the  irrita- 
tion of  the  cerebrospinal  nerves,  and  the  reflected  pain  is  the  result 
of  irritation  to  the  sympathetic  nervous  system.  Later,  should 
inflammation  ensue  and  the  outer  coat  of  the  ureter  be  involved, 
the  local  is  more  prominent  than  the  reflected  pain ;  and  if  the 
adjacent  tissues  are  affected  the  local  pain  far  outshadows  the 
670 


THE    URETER  671 

reflected.  Generally,  however,  such  fine  distinctions  cannot  he 
made  in  practice,  yet  if  it  were  possible  to  follow  a  case  of 
ureteral  stone  colic  from  its  incipiency  to  its  conclusion,  such  a 
transgression  from  reflected  to  local  jDain  might  sometimes  be 
found,  and  the  presence  or  absence  of  inflammation  exactly  de- 
fined. This  is  easier  if  the  obstruction  is  incomplete,  but  at  the 
same  time  sufiiciently  irritative  to  cause  inflammatory  reaction. 

According  to  Ashton,  "When  the  ureter  is  inflamed  pain  is 
elicited  at  the  brim  of  the  pelvis,  about  one  to  one  and  one-quarter 
inches  on  either  side  of  the  promontory  of  the  sacrum,  and  over 
the  upper  or  renal  portion  by  deep  palpation."     (See  Fig.  1.55.) 

A  reference  pain  due  to  stone  in  the  ureter  which  would  seem 
to  be  of  value  is  given  by  Bennett.  In  this  case  a  stone  lodged  in 
the  vesical  end  of  the  right  ureter,  and  caused  more  or  less  con- 
stant 'pain  in  the  right  groin.  The  pain  was  never  acute  and 
rarely  was  entirely  absent.  It  was  worse  in  the  morning  on  leav- 
ing the  bed,  and  again  in  the  evening.  Possibly  a  little  increase 
of  the  pain  was  noted  when  the  bladder  was  full.  On  removal  of 
the  stone  the  pain  ceased  (Bennett).  According  to  Howell  (287, 
p.  445)  the  pain  in  renal  colic  is  felt  at  a  point  a  little  below  the 
ninth  costal  cartilage  in  the  mid-clavicular  line,  from  which  it 
runs  downward  to  the  testicle  and  along  the  inner  side  of  the 
thigh,  following  the  cutaneous  distribution  of  the  eleventh  and 
twelfth  dorsal  and  the  first  lumbar  nerves. 

Should  obstruction  be  complete  the  pain  of  distention  occurs 
pari  passu  with  that  of  the  spasm.  The  distention  of  the  renal 
pelvis  first  occurs,  and  therefore  the  first  organ  to  be  affected  by 
the  distention  is  the  kidney.  It  reacts  to  it  and  causes  a  sense  of 
aching,  tenderness,  and  pain  in  the  lumbar  region. 

Tumors  of  the  ureter  as  a  rule  are  not  painful  unless  they 
cause  a  sudden  obstruction  to  the  ureter,  either  from  pressure,  or 
from  inflammatory  swelling  due  to  an  acute  infection.  They  may 
also  cause  pain  by  the  pressure  of  the  ureteral  mass  upon  the  sur- 
rounding structures.  Depending  upon  the  location  of  the  mass, 
either  local  or  referred  pain,  or  both,  may  be  produced. 

Piersol  ("Anatomy,"  first  ed.,  p.  1914)  gives  a  good  idea  of 


672      THE  URETER,  BLADDER  AND  URETHRA 

the  route  of  pain  reference  in  kidney,  nreter,  and  bladder  diseases. 
He  sajs :  ''The  skin  of  tlie  scrotum  and  penis  is  supplied  with 
sensation  from  the  same  spinal  segments  as  is  the  bladder,  and 
therefore  the  referred  pain  in  vesical  irritation  or  inflammation  is 
often  felt  in  those  regions  in  the  distribution  of  the  perineal 
branches  of  the  pudic  and  the  inferior  gluteal  nerves.  The  tick- 
ling or  itching  around  the  anus,  or  painful  contraction  of  the 
sphincter,  which  may  be  present,  is  the  referred  sensation  through 
the  inferior  hemorrhoidal  nerve  from  the  sacral  plexus.  Lumbo- 
sacral pain  is  felt  through  the  communications  between  the  sec- 
ond, third,  and  fourth  sacral  nerves  and  the  hypogastric  plexus. 
Pains  in  the  area  usually  associated  with  the  kidney  disease  are 
due  to  the  junction  in  the  spermatic  plexus  of  filaments  from 
both  the  renal  and  the  vesical  j^lexuses.  Pain  over  the  kidney 
region  may  also  be  due  to  the  involvement  of  the  spinal  nerves. 
Pains  in  the  lower  limbs,  especially  in  the  foot  (podod^Tiia),  are 
produced  by  the  irritation  carried  through  the  sacral  nerves  into 
the  sacral  plexus  and  the  lumbosacral  cord,  which  give  off  the 
great  sciatic  nerve." 

THE    BLADDER 

GENEEAL  CONSIDEEATIONS 

Anatomy. — The  bladder  is  next  to  the  last  division  of  the 
urinary  apparatus,  and  acts  as  a  reservoir  for  the  urine.  It  is 
very  loosely  attached  to  the  surrounding  structures,  and  can  be 
subjected  to  great  distention  before  it  causes  inconvenience  to, 
or  pressure  on,  adjacent  organs ;  but  when  it  is  so  distended  pain 
and  discomfort  are  most  marked.  The  urinary  bladder  is  unlike 
most  other  abdominal  viscera  because  of  its  great  distensibility 
(in  this  it  resembles  the  stomach),  and  its  peculiar  position  (being 
almost  extraperitoneal)  and  because  its  cavity  is  in  almost  direct 
contact  with  the  external  air. 

Because  of  this  contact  the  bladder  is  much  more  susceptible 
to  inflammatory  diseases  than  are  the  abdominal  viscera,  which 
are  entirely  intraperitoneal. 

Nerve  Supply. — The  nerve  supply  to  the  bladder,  being  both 


THE   BLADDER 


673 


sympathetic  and  spinal,  grants  to  it  attributes  possessed  by  both 
these  systems.  The  sympathetic  system  keeps  it  in  harmony  with 
the  abdominal  viscera,  while  the  spinal  system  supplies  its  muscu- 
lar coats  and  acts  as  a  finely  sensitized  apparatus  which  quickly 
responds  to  all  harmful  irritations  giving  rise  to  the  sense  of  pain. 
The  sympathetic  nerves  are  distributed  principally  to  the  muscu- 


-[-- CONTRACTION      IMPULSE    FROM    BRAIN 
INHIBITION     IMPULSE    FROM   BRAIN 


WHEN  THE   LESION   15   ABOVE. 
THE   SACIiAL   5ECMENTS. 
SENSATION  WILL  13E  CONVEYED 
TO  BRAIN.  BUT  THE     POWER. 
OF  RETAINING    URINE    WltU 
BE   DESTROYED. 


Fig.    157.- 


-Relationship  Existing  between  Pain  and  other  Sensa- 
tions Arising  in  the  Urinary  Bladder. 


lar  coat.  They  follow  the  arteries  and  are  derived  from  the  vesi- 
cal plexi,  which,  in  turn,  arise  from  the  pelvic  plexi  (Pier- 
sol).  When  the  sjTnpathetic  fibers  are  irritated  the  stimulus  is 
carried  to  the  cord,  and  thence  is  reflected  to  the  body  wall, 
where  it  may  be  felt  as  pain.  When  the  spinal  nerve  filaments 
are  irritated  the  pain  is  referred  to  the  region  of  the  bladder, 
although  its  exact  localization  is  rather  indefinite.  The  sympa- 
thetic nerve  supply  differs  from  the  spinal  in  that,  although  deep 
pressure  pain  perception  is  carried  through  its  fibers,  it  also  car- 
ries stimuli  to  the  cord,  from  which  they  are  referred  as  pain 
to  the  cutaneous  areas  having  their  nerve  supply  derived  from 
the  same  segment. 


674 


THE  URETER,  BLADDER  AND  URETHRA 


The  sympathetic  fibers  are  derived  principally  from  the  vesi- 
cal plexus,  which  is  in  direct  communication  with  the  second, 
third,  and  fourth  lumbar  segments  of  the  cord,  and  it  is  through 
these  communications  that  motor  impulses  are  carried  to  the 
bladder  wall.  The  vesical  plexus  communicates  with  the  hj^po- 
gastric  plexus,  which,  in  turn,  communicates  with  the  second, 
I 


I' I  It 


u 


Fig.  158. — Pain  Areas  Associated  with  Diseases  of  Bladder.    (Accord- 
ing to  Head.) 
The  2d,  3d  and  4th  sacral  areas  are  the  ones  in  which  the  bladder  pains 

are  usually  referred. 

third,  and  fourth  sacral  nerves.  This  supply  is  sensory,  as  can 
be  seen  from  the  diagram. 

That  the  pain  sensation  is  carried  through  the  nerve  fibers 
which  are  derived  from  the  sacral  segments  is  apparent,  because, 
in  a  lesion  of  the  twelfth  dorsal  segment,  ordinary  sensations 
from  the  bladder  are  lost;  but  if  the  lesion  is  below  the  first  and 
second  sacral  segTaents  sensation  is  not  lost. 

The  cord  zones,  in  relationship  with  the  bladder,  are  given 


THE   BLADDER 


675 


above.  These  are  not  so  useful  in  the  defining  of  bladder  lesions, 
because  the  intensity  of  the  pain  from  almost  every  painful  lesion 
of  the  bladder  is  so  great  that  it  overwhelms  the  localizing  sense, 
so  that  it  is  almost  impossible  to  define  the  zonal  areas.  The 
areas  most  commonly  affected  in  bladder  lesions  are  the  second 
and  third,  and  possibly  the  fourth  sacral.  It  is  possible  also  that 
sensation  may  be  referred  through  the  second,  third  and  fourth 
lumbar  nerves,  though  such  a 
reference  is  very  unusual. 
That  it  may  occur  is  certain,  as 
is  maintained  by  Head,  "who 
says  that  "in  those  cases  where 
there  is  distention  of  the  blad- 
der, and  ineffectual  attempts 
are  made  by  the  patient  to 
evacuate,  the  pain  is  of  a  sharp, 
shooting  character,  radiating 
from  the  lower  lumbar  and 
sacral  regions  behind,  around 
the  ilium  to  the  lower  part  of 
the  abdomen  just  above  the 
pubes,  and  also  down  the  inner 
side  of  the  thigh  to  the  knee." 
The  pain  may  also  extend  to 
the  outer  side  of  the  thigh. 

The  accompanying  drawing 
(Fig.  159)  illustrates  the  relationship  of  rectal  tenesmus  to  ves- 
ical tenesmus  and  the  method  of  reference  of  bladder  pain  into 
the  penis. 

The  reference  areas  of  bladder  pains  have  been  nicely  illus- 
trated in  Figure  160,  which  represents  the  pain  of  cystitis,  fol- 
lowing instrumental  crushing  for  the  removal  of  stone.  These 
drawings,  which  were  taken  from  Head  ('^Brain,"  Vol.  16,  p.  82), 
represent  points  of  maximal  tenderness,  which  were  found,  (1) 
over  the  ischial  tuberosity,  (2)  over  the  lower  part  of  the  sacrum, 
and  (3)  over  the  tip  of  the  glans  penis. 


Fig.  159. — Relationship  of  Rectal 
Tenesmus  to  Vesical  Tenesmus. 

The  transmission  is  through  the 
pudic  nerve  which  also  suppUes 
the  prostate  and  the  glans  penis. 
When  SLuy  of  these  regions  are 
affected  it  is  common  to  have 
pain  referred  to  any  one,  or  all 
three,  of  the  three  regions. 


676 


THE  URETER,  BLADDER  AND  URETHRA 


Causes  of  Pain. — All  direct  bladder  pains  are,  of  course,  due 
to  irritation  of  sensitive  spinal  nerve  filaments  in  the  bladder  walls. 
Some  of  the  indirect  pains  are  due  to  pressure,  dragging  or  pulling 
upon  the  adjacent  pcrivesicular  structures.  Generally  lesions  of 
the  bladder  proper  are  not  painful  unless  they  encroach  directly 
upon  the  trigone,  for  this  is  the  only  part  of  the  bladder  which  is 


Area  of  distribution  in 
bladder  case 


Sacral  4th  /    'm': 
Sacral  3d  -  -  -' 


Sacral  4th 

Maximum  tenderness  sacral 
4th 

Area   of    maximum   tender- 
ness sacral  3d 
Sacral  3d 


Fig.  160. — Areas  of  Referred  Pains  Usually  Associated  with  Disease 
OF  Urinary  Bladder.     (According  to  Head.) 


extremely  sensitive.  Even  in  the  absence  of  inflammation,  touch- 
ing of  it  by  a  sound  or  probe  is  provocative  of  the  most  intense  dis- 
tress. How  much  more  this  distress  is  increased  when  the  mem- 
brane is  inflamed  can  easily  be  surmised.  If  it  is  inflamed,  and 
there  is  also  increased  irritation  associated  with  a  sharp  and 
jagged  calculus,  it  is  apparent  that  every  time  the  bladder  walls 
contract  a  sharp  and  agonizing  pain  is  bound  to  result.  If  adhe- 
sions exist  between  the  bladder  and  adjacent  organs,  pulling  and 


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677 


678      THE  UKETER,  BLADDER  AND  URETHRA 

dragging  by  these  viscera  at  the  time  of  the  greatest  activity 
will  produce  pain.  Should  the  bladder  (in  the  male)  be  adherent 
to  the  rectum,  or  to  the  sigmoid,  all  evacuations  of  the  bowel  will 
be  attended  with  more  or  less  urinary  tenesmus  and  localized 
bladder  pain.  Likewise,  adhesions  to  the  uterus  and  tubes  in  a 
female  will  produce  the  most  severe  pain  during  the  periods  of 
menstruation,  during  pregnancy,  or  during  sexual  intercourse. 
In  some  cases  the  bowel  and  urinary  bladder  have  become  adher- 
ent. In  these  the  pain  occurs  at  irregular  intervals,  and  is  fre- 
quently accompanied  by  the  gurgling  noise  which  betokens  bowel 
contraction.  If  the  adhesions  are  to  the  adjacent  tissues,  pres- 
sure in  the  suprapubic  region  is  painful,  esjiecially  so  if  the 
bladder  is  full.  In  woman  the  bladder  can  be  palpated  more 
easily  than  in  man,  and  surrounding  adhesions  and  inflamma- 
tion, because  of  the  great  tenderness  they  produce,  are  easier 
to  define.  However,  adhesions  never  cause  such  severe  pain  as 
do  intravesicular  lesions. 

Character  of  Pain. — Pain  due  to  lesions  of  the  bladder  is  of 
two  types:  constant  and  paroxysmal.  The  constant  pain  is  of  a 
dull,  aching  character,  and  is  felt  behind  the  symphysis  pubis. 
When  present  it  indicates  a  rather  severe  inflammation  of  the 
bladder  walls,  for  an  inflammation  that  has  not  progressed  beyond 
the  mucous  membrane  will  not  produce  this  marked  pain.  The 
constant  distress,  associated  with  this  lesion,  is  interrupted  by 
paroxysmal  attacks  of  pain  occurring  during  micturition,  slightly 
before  and  at  the  termination  of  the  act,  at  the  time  when  the  two 
opposing  internal  surfaces  of  the  bladder  are  brought  into  forcible 
contact  with  each  other  by  the  contracting  walls.  Should  a  stone 
also  be  present  the  most  severe  pain  is  felt  at  the  end  of  the 
urinary  act ;  in  fact,  the  pain  may  be  so  severe  that  urination  is 
inhibited.  This  pain  may  be  relieved  b}''  changing  or  reversing 
the  position  of  the  patient;  for  instance,  if  during  the  attack  of 
pain  the  patient  lies  do^Am,  the  stone  may  gravitate  away  from 
the  urethral  opening.  The  urinary  flow  is  resumed  and  the 
bladder  pain  ceases. 

Location. — ISTearlv  all  bladder  diseases,  even  those  of  the  least 


THE   BLADDER 


679 


magnitude,  cause  an  aching  in  the  suprapubic  region.  In  some 
cases  this  aching  is  the  only  discomfort  produced  by  the  disease, 
while  in  others  the  aching  progTesses  into  acute,  severe,  and  well- 
marked  pain,  which  may  be  local,  referred,  or  reflected.  If  local 
the  pain  is  due  to  injury  of  the  terminal  filaments  of  the  sensory 
nerves  of  the  bladder  wall,  which  have  become  involved  in  the 


A  —  Congestion  of 
penis 

B — Constant  pain 
in  glans  penis  in- 
dicates: 

1,  Fissure  (mea- 
tus) 

2,  Prostatitis 

3,  Inflammation 
of  the  prostatic 
urethra 

4,  Ulcer  of  the 
urethra 

C — Constant  pain 
in: 

1,  Chronic  pros- 
tatitis 

2,  Commen  cing 
senile  enlarge- 
ment of  the 
prostate 

3,  Encysted  cal- 
culus at  the 
base  of  the 
bladder 

Pain  relieved  by 
micturition  in: 

1,  Acute  prosta- 
titis 


Fig.  164. — Referred  Pain  in  Dis- 
ease OF  the  Bladder  Due  to 
Involvement  of  the  Pudic 
Nerve. 


2,  Tuberculous 
prostatitis 
(quiescent) 

3,  Tuber  cu  lous 
bladder 


Pain    increased    by 
micturition  in: 

1,  Encysted  pros- 
tatitis at  base 
of  bladder  be- 
hind prostate 

2,  Ulceration 

(a)  Catarrhal 

(b)  Tuberculous 

3,  Local  condi- 
tions 

(a)  Sub-ure- 
thral  abscess 

(b)  Inflamma- 
tion of  the 
post  urethra 

(c)  Impacted 
stone 

(d)  Carcinoma 
of  the  bulb 


process.  These  nerves  are  spinal  in  origin,  and  the  pain  is 
perceived  as  coming  from  their  distribution  area.  It  sometimes 
happens,  though,  that  the  pain  is  referred  to  the  distribution 
area  of  some  other  of  the  branches  of  the  nerve  involved,  as 
may  happen,  for  instance,  in  the  pudic;  where,  although  the 
only  irritation  which  may  be  present  is  in  the  branch  ■  supplying 
the  lower  part  of  the  bladder,  the  pain  may  be  felt  in  the  glans 
penis,  or  in  the  anal  sphincter  (see  Fig.  159). 

When  the  pain  is  reflected  it  is  perceived  as  coming  from  the 


680      THE  URETER,  BLADDER  AND  URETHRA 

distribution  areas  of  the  third  and  fourth  sacral  segments.  These 
have  been  shown  on  page  677.  In  this  connection  it  is  well  to 
remember  that  the  areas  in  which  these  pains  are  most  often 
found  are:  (1)  in  the  kidney  area  (probably  the  result  of  the 
backward  stasis)  ;  (2)  over  the  sacrum,  and  (3)  in  the  foot,  fre- 
quently in   the  heel. 

Time  of  Pain  Attacks. — There  is  no  special  time  at  which  blad- 
der jDain  is  at  its  maximum,  although  from  experience  with  quite 
a  number  of  cases  it  seems  that  night,  with  its  quiet  and  peace, 
is  the  time  when  the  poor  unfortunate  cystitic  feels  and  suffers  the 
most  distress.  Often  he  fears  the  darkness  more  than  the  un- 
godly fear  the  evil  one,  for  never  does  it  bring  sleep,  but  always 
anguish  and  pain. 

Why  he  should  suifer  so  much  more  at  night  is  rather  hard  to 
say;  perhaps  it  may  be  that  at  this  time  the  senses  are  more 
acute.  During  the  night  they  are  relaxed  from  general  care,  and 
perceive  slighter  irritations  than  otherwise  would  merit  their  atten- 
tion. Another  reason  is  that  at  night  congestion  of  the  retro- 
prostatic  plexus  of  veins  occurs.  This  produces  pressure  upon 
the  prostatic  nerves  and  possibly  also  upon  the  sensitive  trigone, 
and  so  gives  rise  to  pain.  It  may  also  happen  that  the  bladder  is 
fuller  at  night  than  during  the  day,  and  thus  pain  is  more  apt 
to  be  produced. 

The  above  description  applies  to  all  cases  except  those  in 
which  a  stone  is  j^resent  in  the  bladder.  When  such  is  the  case 
the  pain  is  generally  worse  in  the  daytime  because  of  the  motion 
which  then  occurs. 

Position  of  Patient.' — The  position  assumed  by  the  patient 
during  urinary  bladder  pain  when  walking  is  one  in  which  he 
stoops  slightly  forward,  in  a  posture  similar  to  that  assumed  in 
enteroptosis. 

When  a  stone  is  in  the  bladder  the  patient  frequently  bends 
forward,  and,  if  a  male,  tugs  at  the  foreskin  of  the  penis.  This, 
in  some  cases,  seems  to  give  relief.  Why,  it  is  difficult  to  say. 
Distention  of  the  bladder  also  causes  the  patient  to  bend  for- 
ward. 


THE   BLADDER  681 

The  prone  position  is  not  so  often  sought  by  the  person  sub- 
ject to  bladder  derangement.  As  a  rule  he  likes  best  to  sit  on  a 
chair,  bent  forward,  with  his  elbows  on  his  knees.  Sometimes  he 
makes  pressure  over  the  region  of  the  bladder,  though  if  the  in- 
flammation is  severe  he  does  so  very  carefully. 

Factors  Influencing  Production  of  Pain. — E elation  of  Urinary 
Bladder  Pain  to  Motion. — One  who  is  troubled  with  chronic  blad- 
der disease  is  not  very  active  muscularly.  Slow,  calm,  and  de- 
liberate in  all  his  movements,  he  seems  the  perfect  embodiment  of 
caution.  He  will  not  run,  jump,  ride  in  springless  wagons,  nor 
in  jolting  cars ;  even  walking  may  become  distasteful  to  him.  His 
life  is  one  living  torment,  for  exevj  motion  hurts  and  injures  him. 
Even  rest  in  bed  may  be  denied  him,  for  it  may  prove  to  be  only 
a  snare  with  which  to  increase  his  pain.  Yet  he  goes  on  hoping, 
always  hoping  for  a  surcease  from  pain. 

Relation  of  Food  and  Drink  to  Bladder  Pain. — In  food  and 
drink  lie  hidden  dangers,  for  the  first  may  produce  bowel  dis- 
orders which  are  distressing,  and  the  second  may  produce  urine 
which  burns  and  scorches.  Both  bring  added  discomfort  to  an 
already  overburdened  soul. 

Drugs  sometimes  cause  an  attack  of  bladder  pain.  Witness 
the  frequency  with  which  urotropin  initiates  one. 

Cold  air  and  drafts  produce  a  congestion  that  may  stir  up 
latent  disease  and  cause  old  symptoms  of  pain  and  discomfort  to 
appear  again;  or,  in  the  presence  of  an  active  involvement,  they 
may  still  further  augment  the  distress. 

Tenderness  in  Disease  of  the  Bladder. — Diseases  of  the  blad- 
der, when  they  cause  pain,  are  always  accompanied  by  inflamma- 
tion, and  inflammation  as  a  rule  produces  tenderness.  This  ten- 
derness of  bladder  lesions  is  marked  in  the  three  locations  in 
which  it  is  possible  to  make  direct  pressure  upon  the  bladder  by 
the  examining  finger. 

The  first  and  most  prominent  location  is  immediately  above 
the  pubes  in  the  suprapubic  region.  Here  the  fingers  can  be 
pressed  into  the  abdomen  and  then,  by  flexing,  can  be  depressed 
deep  into  the  pelvis.     Should  the  patient  be  a  child  this  latter 


682      THE  URETER,  BLADDER  AND  URETHRA 

procedure  is  not  necessary,  as  in  children  the  bladder  rides  above 
the  pelvic  brim.  The  second  location  is  the  base  of  the  bladder. 
In  woman  the  base  of  the  bladder  may  be  palj^ated  bimaniially 
between  a  finger  placed  in  the  vagina  and  the  palmar  surface  of 
the  other  hand  laid  over  the  abdomen.  If  the  bladder  is  in- 
flamed the  patient  will  complain  of  pain  on  pressure  between 
the  two.  A  stone  in  the  bladder  or  lower  Ureter  can  often  be 
palpated  by  this  method.  A  rectal  examination  frequently  is 
made  in  the  male,  but,  as  a  rule,  is  not  successful  in  eliciting 
symptoms  of  any  value  because  of  the  gTeat  sensitiveness  of  the 
prostate. 

The  third  location  in  which  pain  in  inflammatory  diseases  of 
the  bladder  is  particularly  marked  is  the  trigone.  The  pain  here 
is  elicited  by  the  passing  of  a  catheter,  which  when  it  enters  the 
bladder  produc-cs  the  most  intense  distress. 

Associated  Symptoms. — The  symptom  commonly  associated 
with  disease  of  the  urinary  bladder  is  painful  and  frequent 
urination.  Frequency  of  urination  is  one  of  the  first  signs  of 
bladder  disorder. 

Painful  urination  may  also  be  associated  with  a  new  growth. 
In  the  urethra  the  growth  may  be  a  caruncle,  which  is  a  small 
rasjDberry  mass  lying  to  one  or  the  other  side  of  the  meatus ;  or 
a  cancer  (carcinoma  or  sarcoma).  These  are  nearly  always  ulcer- 
ated and  have  acrid  discharges,  which  give  rise  to  severe  itching. 
If  the  urination  is  painful  and  frequent,  and  pus,  but  no  blood, 
is  present  in  the  urine,  it  indicates  a  cystitis,  in  which  the  pain 
is  of  a  scalding  nature  and  occurs  during  the  entire  time  of 
the  iiassage  of  the  urine.  It  is  most  joronounced  at  the  beginning 
of  the  urinary  act,  and  difficulty  is  often  experienced  in  starting 
the  stream. 

Painful  and  frequent  urination,  with  blood  and  pus  absent 
from  the  urine,  indicates:  (1)  vesicourethral  fissure,  in  which  the 
pain  is  constant  and  is  increased  during  the  urinary  act,  or  (2) 
pressure  upon  the  bladder  by  an  enlarged  uterus,  ovarian  tumor, 
or  inflammatory  mass.  If  painful  and  frequent  urination  occurs, 
with  blood  in  the  urine,  the  examiner  should  seek  for:  (1)  tuber- 


THE   BLADDER  683 

culosis,  in  wliich  the  blood  as  a  rule  is  found  early  in  the  disease 
and  ceases  as  the  disease  advances;  tubercle  bacilli  also  may 
often,  if  persistently  sought,  be  found  in  a  centrifugalized  speci- 
men, while  in  (2)  gonorrheal  disease,  the  gonococcus  may  often 
be  found  on  a  similar  examination;  and  (3)  vesical  calculus,  in 
which  condition  other  signs  and  symptoms  of  the  calculus  are 
present. 

!N^on-painful  and  frequent  urination,  with  hematuria,  generally 
is  the  result  of  tumor,  in  which  the  pain  becomes  noticeable 
only  late  in  the  course  .of  the  disease. 

Differential  Diagnosis. — Bladder  diseases  should  be  diagnosed 
from  involvement  of  the  central  nervous  system.  Here  the  "pain 
occurs  independent  of  micturition  and  radiates  to  the  rectum  or 
to  the  genitals  and  thigh"   (Schmidt). 

BLADDER    AFFECTIONS    CAUSING    PAIN 

The  bladder  lesions  causing  pains  are:  (1)  cystalgia,  (2) 
vesicourethral  fissure,  (3)  distention  of  the  bladder,  (4)  rup- 
ture of  the  bladder,  (5)  cystitis,  (6)  pericystitis,  (7)  tumors, 
(8)  tuberculosis,  and  (9)  calculus. 

Cystalgia.— ^Montgomery  speaks  of  a  cystalgia.  Reed  is  inclined 
to  think  that  this  condition  should  be  described  as  a  hyperemia. 
He  says  that  while  a  neuralgia  of  the  bladder  may  occur,  gener- 
ally it  is  only  a  term  used  for  hyperemia.  Under  the  circum- 
stances a  frequent  desire  to  urinate  is  present,  with  a  burning 
during  or  after  the  act.  Most  of  the  women  so  complaining  are 
of  a  neurotic  temperament,  and  are  afflicted  with  displacement 
of  the  uterus,  movable  kidneys,  etc.  Fenwick  seems  to  believe 
that  neuralgia  of  the  bladder  may  exist  as  a  separate  entity;  and 
that  it  is  probably  produced  by  the  toxins  of  infectious  diseases, 
as  those  of  influenza  or  of  light  septic  infectious.  In  some  cases 
pain  apparently  in  the  bladder  is  due  to  inflammation  of  the 
pudic  nerve.  The  pain  in  this  case  is  also  referred  to  the  penis, 
rectum,  and  perineum.  The  perineal  pain  may  be  so  severe  and 
the  perineal  surface  so  sensitive  that  the  sitting  posture  becomes 


684      THE  URETER,  BLADDER  AND  URETHRA 

almost  imj)ossible.      Traveling   on  cars   also  causes  the   greatest 
agonv. 

Pain  "witli  incontinence  and  frequency  of  urination  should  lead 
to  the  suspicion  of  tabes,  general  paresis,  etc. 

Vesicourethral  Fissure. —In  this  condition  the  pain  as  a  rule 
is  constant,  but  is  more  marked  during  the  urinary  act.  The  con- 
stancy of  the  pain  is  due  to  the  irritation  by  the  urine  of  the  nerves 
exposed  in  the  b3d  of  the  fissure.  It  does  not  seem  to  make 
much  difference  ^vhether  the  urine  is  acid  or  alkaline,  the  pain 
(in  many  cases)  being  equally  severe  in  both,  though  the  neutral 
or  slightly  alkaline  urine  seems  to  produce  the  least  pain.  An- 
other cause  of  the  constant  pain  is  the  steady  pressure  made 
upon  the  exposed  nerves  by  the  contraction  of  the  sphincter.  The 
pain  of  this  condition  differs  from  that  of  cystitis  in  that  it  is 
sharply  circumscribed,  while  the  pain  due  to  cystitis  is  diffuse. 
Urination  in  cystitis  gives  relief  from  pain,  while  in  vesico- 
urethral fissure  the  pain  during  urination  is  increased.  Tender- 
ness, sharp  and  localized  to  the  posterior  urethra,  is  also  present 
in  vesicourethral  fissure,  while  in  cystitis  the  tenderness  is  dif- 
fused. 

Distention  of  the  Bladder. — Distention  of  the  urinary  bladder 
is  not  very  painful  unless  it  is  of  sudden  onset,  when  pain  is  a 
prominent  symptom.  Distention  may  be  due  to  an  acute  urethral 
obstruction  from  a  blocking  of  the  urethra  by  a  calculus  or  a 
clot.  If  the  distention  of  the  bladder  is  the  result  of  lack  of 
sensation  or  of  muscular  power  in  the  bladder,  it  is  likely  due 
to  a  lesion  of  the  brain  or  of  the  cord,  and  may  be  entirely 
painless. 

In  some  cases  the  bladder  may  be  so  encompassed  by  adhe- 
sions to  adjacent  viscera,  the  result  of  inflammatory  exudates  in 
the  pelvis,  that  only  two  or  three  ounces  of  urine  produce  a  pulling 
and  dragging  on  the  adhesions,  and  dull  aching  pain  is  felt  in  the 
areas  and  regions  of  the  viscera  secondarily  involved.  In  these 
conditions  pain  is  most  severe  during  the  urinary  act  because,  by 
the  contraction  of  the  bladder,  traction  is  made  upon  the  sur- 
rounding adhesions  and  pain  is  produced.     This  pain  is  of  a  more 


THE    BLADDER  685 

severe  type  than  the  dull,  aching,  continuous  pain  of  distention, 
and  generally  occurs  as  the  acme  of  a  pain  of  gradually  increasing 
intensity.  This  type  of  pain  is  found  as  a  rule  only  in  the 
female,  because  a  male  is  free  from  pelvic  disease  with  its  result- 
ing adhesions.  The  pain  is  most  frequently  felt  behind  the  blad- 
der. The  intervals  between  the  periods  of  distention  are  free 
from  pain.  The  pain  Avhen  present  may  radiate  along  the  ure- 
thra to  the  (testicles)  anus  and  perineum.  The  two  latter,  in 
common  with  the  bladder,  are  innervated  by  the  sacral  plexus. 
The  pain  may  also  be  propagated  reflexly  to  the  hypochondrium, 
to  both  thighs,  or  be  referred  to  the  regions  innervated  by  the  an- 
terior crural  and  sciatic  nerves.  This  radiation  is  very  common 
in  prostate  tumors. 

Rupture  of  the  Bladder. — Rupture  of  the  bladder  is  indicated 
by  sudden  severe  pain  in  the  lower  part  of  the  abdomen.  It  fol- 
lows a  trauma,  and  is  associated  with  a  constant  desire  to  urinate. 
On  attempting  to  urinate  no  urine  may  pass,  though  the  desire 
does  not  abate.  If  any  urine  is  passed  it  is  mixed  with  blood.  In 
addition,  tenderness  over  the  lower  abdomen  in  the  prevesicular 
region  is  most  marked.  All  cases  of  rupture  of  the  bladder  are  not 
accompanied  by  pain.  A  case  in  point  is  related  by  Moullin 
(226,  p.  514)  of  a  man  wdio  twenty-four  hours  after  an  accident 
walked  into  the  hospital  and  complained  of  his  inability  to  pass 
urine.     Examination  disclosed  a  ruptured  bladder. 

Cystitis. — Inflammation  of  the  bladder  is  always  accompanied 
by  pain.  The  cause  of  this  pain  production  undoubtedly '  is  the 
irritation  of  the  sensory  receptors  in  the  bladder  mucosa  and  of 
the  sensory  fibers  in  the  bladder  wall  structure.  This  irritation 
produces  more  pain  when  it  occurs  in  the  region  of  the  trigone. 
When  it  is  present  there,  the  entire  urinary  act  may  be  painful, 
though  the  pain  is  most  marked  at  the  end  of  the  act. 

Character  of  the  Pain. — In  mild  forms  of  cystitis  the  only 
annoyance  may  be  a  slight  discomfort  at  the  time  of  urination  or 
shortly  before  it,  or  if  pain  is  present  it  is  more  of  a  burning 
or  scorching  of  the  urethra  after  urination  than  a  true  pain. 
This  peculiar  sensation  disappears  between  the  urinary  acts,  to 


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Urine  is  bloody,  or  maj'  be  en- 
tirely absent,  owing  to  the  in- 
ability of  the  patient  to  urinate. 

Is  present  in  the  perineum  and 
scrotum,  soft  and  boggy  to  the 
touch.     Ecchymosis  is  marked. 

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No  blood  may  be  present.      Urine  less 
in   amount.     Urethral   catheterization 
may  disclose  no  urine  coming  from  the 
injured  kidney.      Desire  to  urinate  not 
so  marked.     Blood,  when  it  is  present, 
is   evenly   mixed   with   the   urine.     If 
urine  is  coming  from  the  injured  kid- 
ney and  no  blood  is  mixed  with  it, 
rupture  has  not  occurred. 

Is  present  in  the  lumbar  region,  and 
produces  a  well-marked  swelling.    This 
formation  fluctuates. 

If  the   rupture  is  intraperitoneal,    no 
tumor  formation  will  be  present  in  the 
loins,  but  intraperitoneal  fluid  will  be 
definable. 

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Injury  has  been  to  lumbar  region,  or 
in    some    cases    to    the    abdomen.     A 
crush  between  bumpers   of   cars   will 
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Contains    blood.     On    catheterization, 
urine  may  be  absent  from  the  bladder. 
Frociuent  and  painful  urination.    Urine 
or  blood  may  not  be  passed,  though 
the  desire  to  urinate  remains. 

If   the  rupture  is  extraperitoneal,  the 
tumor  mass  is  in  the  lower  abdomen 
and  rides  above  the  symphysis  pubis, 
and    fluctuation    is   present    over    the 
symphysis  pubis.  If  the  rupture  is  intra- 
peritoneal,   tumor  formation   may  be 
entirely  absent,  but  fluctuation  will  be 
present  in  the  abdomen. 

Catheter  easily  enters,  but  passes  into 
peritoneal  cavity  or  adjacent  area  be- 
cause of  rent  in  bladder  wall. 

Injury  has  generally  been  a  crush,  in 
which  a  fracture  of  the  pelvis  has  been 
produced.     Any  sort  of  a  trauma  to 
the  suprapubic  region  may  cause  rup- 
ture of  the  bladder. 

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686 


THE   BLADDER  687 

recur  when  the  urine  is  passed.  The  severity  of  the  pain  varies 
with  the  intensity  of  the  inflammation.  In  severe  grades  of  in- 
flammation the  pain  is  most  marked.  In  some  cases  nrinary 
tenesmus  is  so  great  that  the  unfortunate  sufferer  is  compelled 
to  sit  on  the  urinal  for  hours  before  he  has  relief  from  the  in- 
sistent desire  to  urinate.  In  the  severest  forms  of  cystitis  the 
patient's  life  is  a  living  torment.  Goaded  by  a  constant  and  un- 
satisfied desire  to  urinate,  with  the  most  severe  pain  and  local 
tenderness  over  the  bladder,  his  existence  may  be  said  to  be  a 
li\dng  hell.  In  chronic  cystitis  pain  is  not  as  severe  as  it  is  in 
the  acute.  Should  the  pain  occur  only  at  the  end  of  the  urinary 
act  it  indicates  that  the  disturbance  is  in  the  trigone  and  the 
posterior  urethra.  The  lesion  most  likely  to  cause  this  pain  is 
inflammation,  which  in  many  cases  is  of  gonorrheal  origin.  In 
some  cases,  spasm  of  the  urethra  ensues,  and  the  patient  is  unable 
to  urinate  without  the  greatest  pain.  This  pain  may  be  so  great 
that  he  is  loath  to  perform  the  act,  and  a  partial  retention  of 
urine  results.  However,  in  cystitis  pain  is  not  always  present, 
and  may  be  absent  for  considerable  periods ;  and  even  when  pres- 
ent may  at  times  be  eased  to  such  an  extent  that  the  patient  is 
fairly  comfortable.  Then  suddenly,  often  without  any  apparent 
cause,  there  ensues  a  very  severe,  painful  and  active  paroxysm. 

Location  of  the  Pain. — The  pain  of  cystitis  may  be  either 
local  or  referred.  The  local  pain  is  felt  both  in  the  urethra  and 
in  the  suprapubic  region.  In  the  urethra  it  is  most  severe  during 
or  before  the  urinary  act,  though,  if  the  trigone  is  involved,  it 
may  be  most  severe  at  the  end  of  the  act.  In  the  suprapubic 
region  the  pain  is  felt  more  as  a  dull,  constant  aching,  increased 
at  time  of  urination.  Both  of  these  pains  are  due  to  the  irrita- 
tion of  the  terminal  filaments  of  the  cerebrospinal  nerves  supply- 
ing the  bladder.  When  the  base  of  the  bladder  is  involved  the 
inflammation  may  be  communicated  to  the  rectum,  and  severe 
rectal  tenesmus  may  then  result. 

The  referred  pain  is  present  in  the  skin  of  the  scrotum  and  the 
penis.  These  (Piersol)  are  supplied  by  the  perineal  branches  of 
the  pudic  and  inferior  gluteal  nerves,  which  are  derived  from  the 


688      THE  URETER,  BLADDER  AND  URETHRA 

same  segment  of  the  cord  as  are  the  nerves  supplying  the  bladder, 
so  that  irritation  from  the  bladder  may  be  carried  to  the  cord 
and  thence  referred  through  these  nerves  to  their  distribution 
area.  The  pain  in  the  lower  limbs  and  foot,  especially  the  foot 
pain  (podalgia),  is  due  to  the  transmission  from  the  sacral 
nerves,  which  form  the  pelvic  plexus,  to  the  lumbosacral  cord, 
which  is  formed  into  the  great  sciatic.  Tickling  or  itching 
around  the  anus  and  painful  contraction  of  the  anal  sphincter 
(rectal  tenesmus)  are  present  at  times,  and  are  most  marked 
when  the  trigone  is  affected.  Lumbosacral  pain  is  also  present. 
In  some  cases  of  cystitis  pain  has  been  felt  in  the  region  of  the 
umbilicus,  w'ith  at  the  same  time  an  entire  absence  of  bladder 
tenderness  (Hilton).  The  pain  may  also  be  referred  to  the  kid- 
ney region.  In  some  instances  pain  due  to  a  lesion  at  the  fundus 
of  the  bladder  may  be  referred  to  the  head  of  the  penis. 

Tenderness. — In  cystitis  tenderness,  as  a  rule,  is  present  in 
the  suprapubic  area;  but  Hilton  reports  a  case  in  which  the 
tenderness  to  light  pressure  was  a  little  to  the  left  of  the  umbili- 
cus, and  pain  to  deep  pressure  was  present  toward  the  loin,  no 
tenderness  being  felt  over  the  bladder  region.  The  superficial 
tenderness,  it  seems  likely,  was  due  to  some  other  factor  than  the 
cystitis.  The  tenderness  in  bladder  lesions  is  most  marked  at 
the  time  of  the  painful  paroxysms.  In  examining  for  tender- 
ness, pain  is  more  frequently  produced  by  sudden  withdrawing 
of  the  hand  pressure  than  by  deep  palpation. 

If  the  tenderness  is  marked,  and  the  point  of  greatest  ten- 
derness is  in  the  suprapubic  region,  cystitis  is  probably  present. 
This  area,  in  inflammatory  states  of  the  bladder,  is  very  sensitive 
either  to  palpation  or  to  percussion.  In  some  it  is  so  sensitive 
that  they  cannot  bear  to  have  the  clothing  touch  it. 

Factors  influencing  attacks  of  pain  in  cystitis  are: 

(1)  Anything  which  causes  a  congestion  of  the  bladder  mu- 
cosa or  musculature,  such  as  exposure  to  cold,  dampness,  menstru- 
ation, diarrhea,  constipation,  or  exposure  to  drafts.  These  mav 
produce  an  attack  or  cause  an  exacerbation  of  one  already  present, 


THE   BLADDER  689 

(2)  Instrumentation,  especially  if  it  is  at  all  rough,  brings 
on  an  acute  and  severe  attack  of  pain. 

(3)  Digestion  at  times  is  also  responsible  for  the  production 
of  an  attack. 

The  symptoms  associated  with  a  cystitis  are:  (1)  frequency 
of  urination,  (2)  alkalinity  of  the  urine,  (3)  the  presence  of  pus 
and  bacteria  in  the  urine  (the  bacteria  found  are  those  which 
have  been  the  chief  factors  in  causing  the  cystitis),  and  (4)  blood 
in  the  urine.  This  last  indicates  a  cystitis  of  considerable  se- 
verity, and  is  nearly  always  found  in  gonorrheal  and  tuberculous 
cystitis,  and  in  the  later  stages  of  the  cystitis  due  to  bladder 
tumors. 

Pericystitis. — Should  pain  and  tenderness  be  present  in  the 
bladder  region,  and  be  associated  with  a  mass  either  in  the  median 
line  or  to  one  side,  and  should  this  follow  instrumentation  or 
trauma  to  the  bladder,  it  is  a  good  sign  that  pericystic  inflamma- 
tion has  occurred.  This  lesion  produces  a  constant,  severe  throb- 
bing or  aching  pain,  made  worse  on  urinating.  If  the  process 
continues  an  abscess  may  form. 

Tumors  of  the  Bladder. — Pain  in  tumors  of  the  bladder  is  of 
no  practical  moment,  either  as  an  aid  in  the  making  of  a  diag- 
nosis or  in  deciding  how  far  the  process  has  advanced.  It  is 
more  prominent  in  carcinoma  than  in  other  tumors  of  the  blad- 
der, probably  because,  in  this  form  of  malignancy,  the  walls 
quickly  become  infiltrated  and  pressure  is  made  upon  the  sensory 
terminal  filaments.  The  infiltration  also  hinders  the  contraction 
of  the  bladder  muscles.  When  under  these  circumstances  cystitis 
develops  it  is  very  serious,  and  the  pain  incident  to  it  is  most 
severe.  Tenesmus,  out  of  all  proportion  to  the  size  of  the  tumor, 
is  nearly  always  present  in  malignant  tumors  of  the  bladder  wall. 

Tumors  of  the  bladder,  because  they  may  block  the  ureters, 
and  thus  cause  a  back  pressure  and  distention  of  the  renal  pelvis, 
also  at  times  give  rise  to  kidney  pain.  As  a  rule  the  malignant 
tumors  are  the  only  ones  which  are  very  painful,  the  pain  vary- 
ing in,  direct  proportion  to  the  nearness  of  the  growth  to  the 
trigone.     The  reason  why  malignant  tumors  are  so  painful  is 


690      THE  URETER,  BLADDER  AND  URETHRA 

that  as  a  rule  thej  are  very  friable,  and  pieces  of  the  tumor 
mass  frequently  slongh  off.  These  pieces,  and  in  some  cases 
blood  clots,  are  carried  to  the  urethra.  If  they  are  not  able  to 
pass,  a  blocking  occurs,  and  bladder  distention,  which  is  painful, 
results.  In  other  cases  the  carcinomatous  tissue  invades  the 
wall  of  the  bladder ;  when  it  does  so,  on  each  contraction  of  the 
bladder,  pain  is  produced  by  the  pressure  made  by  the  contractr 
ing  muscles  U2:)0n  the  terminal  sensory  nerve  filaments  in  the 
bladder  wall.  The  tumor  cells  may  also  progress  beyond  the 
bladder  walls  and  involve  neighboring  structures.  Then  pain 
due  to  interference  with  their  functions  may  be  produced,  and  be 
referred  to  the  distribution  areas  of  the  organs  involved.  The 
tumor  cells  may  also  infiltrate  adjacent  sensory  nerves.  When 
they  do  so,  severe,  continuous,  dull,  aching  pain  is  referred  to  the 
distribution  area  of  the  nerves  involved. 

Tuberculosis  of  the  Bladder. — Causes  of  Pain. — In  tubercu- 
losis of  the  bladder  the  greatest  pain  is  felt  in  those  cases  in  which 
the  trigone,  the  prostate,  or  the  deep  urethra  are  involved.  It 
may  cause  the  most  severe  suffering.  Infections  of  the  upper 
part  of  the  bladder  are  not  so  painful  as  those  of  the  lower  part. 

According  to  Fenwick,  the  pain  of  bladder  tuberculosis  de- 
pends upon  the  depth  of  the  ulceration,  the  state  of  the  phos- 
phatic  deposit,  the  presence  of  exposed  nerves,  and  the  degree  to 
which  the  eroded  edges  are  stretched  by  the  accumulating  urine. 

''Deep  ulcerations  may  not  produce  any  very  severe  pain,  while 
in  other  eases  congestion  or  slight  ulceration  of  the  mouth  of  a 
ureter,  or  a  few  miliary  tubercles  in  the  mucous  membrane  of  the 
trigone  may  increase  the  frequency  of  urination  and  tenesmus, 
and  pain  may  be  excruciating."  (Johnston,  Surg.  Diag.,  Vol. 
II,  p.  440.) 

Character  of  Pain. — Pain  occurs  during  urination.  Gener- 
ally it  follows  a  period'  of  increased  frequency  of  urination, 
which  as  a  rule  has  been  present  for  a  long  period  before  the 
pain  commences.  Gradually  the  frequency  of  urination  and  the 
pain  increase,  so  that  finally  the  patient  is  in  a  stage  of  perma- 


THE   BLADDER  691 

nent  discomfort,  with  constant  urinary  pain  and  tenesmus.  The 
paiu  is  of  a  burning  character. 

Time. — The  severest  pain  is  felt  during  the  urinary  act,  and 
is  most  severe  at  the  end  of  the  act,  when  the  sphincter  closes 
down  upon  the  posterior  urethra.  Sometimes  the  intervals  be- 
tween the  urinary  acts  are  free  from  j)ain ;  at  other  times  j^ain  is 
constant,  being  aggravated  only  at  the  time  of  urination. 

Location. — The  pain  may  be  local,  referred,  or  reflected.  Local 
pain  may  not  be  present,  except  at  the  time  of  urination.  Even 
then  the  pain  may  not  be  localized  to  the  region  where  it  is 
produced,  but  may  be  referred  along  the  urethra  to  the  glans 
penis.  It  is  especially  severe  at  the  end  of  the  act,  at  the  time 
the  sphincter  muscles  close  down  on  the  sensitive  urethra.  The 
other  referred  pains  have  been  described  under  the  general  con- 
siderations of  bladder  pain.  The  reflected  pain  is  present  in  the 
(1)  sacral  region,  (2)  the  kidney  region,  (3)  the  groin,  and 
(4)  the  thighs. 

Factors  Influencing  Production  of  Pain. — Position  does  not 
influence  either  the  onset,  course,  or  severity  of  the  pain.  Motion 
also  does  not  in  the  slightest  degree  modify  or  change  the  pain, 
except  in  the  presence  of  a  cystitis,  when  the  slightest  movement 
may  cause  the  severest  pain. 

Associated  Symptoms. — Associated  symptoms  of  bladder  tuber- 
culosis are: 

(1)  Hematuria,  which  is  present  in  about  ten  per  cent,  of  the 
cases  (Johnson).  It  may  precede  the  onset  of  pain  by  an  appre- 
ciable interval. 

(2)  Polyuria  may  be  present.  It  also  is  frequent  in  renal 
tuberculosis. 

(3)  Pus  is  commonly  found  in  the  urine,  and,  after  a  long 
and  careful  search  of  the  urine,  tubercle  bacilli  are  also,  as  a 
rule,  discovered. 

A  confirmative  sign  of  value  in  the  diagnosis  of  bladder  tuber- 
culosis is  the  presence  of  tuberculous  foci  elsewhere  in  the  body. 

Foreign  Bodies  in  the  Bladder. — Foreign  bodies  may  be  pres- 
ent   in   the   bladder   without   producing   pain;    however,    this    is 


692      THE  URETER,  BLADDER  AND  URETHRA 

true  onlj  in  those  cases  in  which  the  foreign  body  has  no  sharp 
edges,  or  in  those  in  which,  by  its  position,  it  does  not  interfere 
with  the  emptying  of  the  bladder.  The  usual  way  in  which  a 
sharp,  pointed  foreign  body  can  cause  pam  is  by  penetration  of 
the  bladder  wall  and  the  starting  of  an  inflammation,  either  of 
the  perivesicular  tissues  or  of  the  peritoneum.  The  peritoneal 
inflammation  will  produce  signs  of  a  peritonitis,  while  the  peri- 
vascular inflammation  will  provoke  the  symptoms  of  a  pericys- 
titis.    (See  under  the  appropriate  headings.) 

A  history  of  the  introduction  of  a  foreign  body  into  the  ure- 
thra, and  its  lodgment  in  the  bladder,  followed  by  vesicular  pain, 
is  presumptive  evidence  that  the  foreign  body  is  the  cause  of  the 
pain.  If  the  body  shoul(J  lodge  in  certain  parts  of  the  bladder, 
such  as  the  posterior  prostatic  space,  especially  if  the  space  is 
ample,  as  it  is  in  those  W'ho  are  old  and  have  large  prostates,  little 
pain  results.  In  these  patients  the  bladder  walls,  on  account  of 
the  peculiar  configuvation  of  the  parts,  will  not  be  able  to  contract 
upon  the  object,  and  localized  irritative  pressure  will  be  absent. 
One  of  the  commonest  foreign  bodies  present  in  the  bladder  is  a 
calculus.  Foreign  bodies  of  the  greatest  variety  may  occasionally 
be  found  in  the  female  bladder.  Over  a  hundred  different  objects 
have  been  found  in  a  single  bladder.  Such  patients  use  such 
bodies  deliberately  for  urethral  titillation.  During  use  they  fre- 
quently slip  into  the  bladder  by  accident  or  are  placed  there  by 
design. 

Vesical  Calculus. — Causes  of  Pain. — Stone  in  the  urinary 
bladder  generally  causes  pain,  the  amount,  variety,  and  constancy 
of  which  depend  on  the  position  of  the  stone,  its  size  and  shape, 
and  the  condition  of  the  bladder  wall. 

If  a  stone  is  located  at  the  opening  of  the  urethra  it  always 
produces  more  pain  than  it  would  if  it  were  located  in  any  other 
part  of  the  bladder.  This  pain  is  the  result  of  interference  with 
the  proper  emptying  of  the  viscus.  In  these  cases,  the  bladder 
walls,  when  they  contract,  are  brought  into  contact  with  the  stone, 
which,  if  sharp  and  irregular,  causes  the  most  severe  pain.  Often 
a  small  stone,  if  rough  and  irregular,  will  produce  much  greater 


THE   BLADDER  G93 

distress  and  pain  than  a  larger  one  witli  a  more  regular  outline.^ 
If  the  bladder  wall  is  not  irritable  a  stone  may  be  present  for 
long  periods  of  time  without  causing  the  least  annoyance.  This 
also  happens  if  the  calculus,  because  of  its  fixation  in  a  diverticu- 
lum, be  immovable,  so  that  it  cannot  irritate  the  bladder  wall. 
Should  the  stone  be  rough  and  freely  movable,  and  in  constant 
contact  with  the  trigone,  it  causes  very  severe  and  constant  pain. 
This  pain  is  very  much  increased  during  urination,  especially 
toward  the  end  of  the  act,  but  may  be  entirely  absent  if,  because 
of  incomplete  contraction,  the  bladder  does  not  make  pressure 
upon  the  stone.  If  the  stone  lies  in  a  pouch  or  depression  of 
the  bladder  wall,  or  is  lodged  behind  an  enlarged  prostate,  pain 
may  also  be  absent.  It  is  also  much  less  in  the  aged,  because 
of  the  comparative  insensibility  of  their  bladder  mucosa.  Renal 
hyjDeremia  and  congestion  generally  accompany  vesical  stone; 
these  cause  parenchymatous  enlargement  of  the  kidney,  and  so 
produce  pains  which  are  referred  to  the  kidney  area,  so  that  in 
some  cases,  even  when  the  lesion  is  in  the  bladder.  Head's  kidney 
zones  may  be  present.  In  such  cases,  also,  the  ureteral  areas  may 
be  free  of  pain,  while  the  vesicular  and  the  kidney  areas  may  be 
hyperalgesic ;  also  the  typical  colic  of  ureteral  stone  may  be 
absent. 

Character  of  the  Pain. — The  pain  of  vesicular  calculus,  while 
it  lasts,  is  very  severe.  If  a  cystitis  develops,  the  constant  pain 
may  be  interrupted  by  sharp,  severe,  spasmodic  attacks,  initiated 
by  urination.  The  pain  is  most  pronounced  at  the  end  of  the  act, 
and  may  persist  for  some  time  after.  Some  patients,  while  un- 
able to  urinate  comfortably  in  any  other  position,  can  do  so  with- 
out pain  if  they  lie  upon  their  backs.  Sometimes  the  pain  is  of 
such  a  character  that  the  patients  seem  to  gain  ease  by  pulling  up 
the  foreskin  after  urinating.  The  pain  is  always  most  severe  in 
those  in  whom  the  bladder  presses  do\Mi  upon  and  comes  into 
direct  contact  with  the  stone. 

1  Calculi  of  oxalate,  of  lime,  or  of  phosphate  are  the  roughest.  Those  of 
cystin  and  uric  acid  are  generally  more  round  and  smoother  than  the  former, 
and  cause  less  pain. 


694      THE  URETER,  BLADDER  AND  URETHRA 

Location  of  the  Pain  of  Vesical  Calculus. — The  pain  may  be 
either  local,  referred,  or  reflected.  The  local  pain  is  felt  in  the 
suprapubic  region  and  in  the  deep  urethra.  Keferred  pain  is  felt 
in  the  glans  penis,  the  perineum,  or  the  anus,  the  reference  taking 
place  through  the  respective  branches  of  the  pudic  nerve.  The 
pain  likewise  may  be  reflected  through  the  nerve  fibers  arising 
from  the  third  and  fourth  sacral  and,  in  some  instances,  from  the 
second  sacral  visceral  segments.  Through  these  nerves  reflection 
occurs,  so  that  the  pain  is  felt  as  coming  from  the  thighs,  the 
hips,  the  sacral  region  and,  in  some  cases,  from  the  shoulders  and 
the  anus.  A  sensation  is  often  felt  as  though  a  paper  of  pins 
were  in  the  rectum  (Keen).  These  referred  and  reflected  pains 
are  always  worse  when  the  bladder  is  full,  or  when  the  patient 
assumes  the  erect  posture.  In  some  cases  the  pain  is  radiated  into 
the  area  of  the  distribution  of  the  lumbar  plexus.  It  is  also  said 
(Head  quC'ting  from  Erickson)  that  in  some  cases  there  is  a 
dragging  sensation  in  the  groins,  and  frequently  a  pain  in  the 
soles  of  the  feet. 

Factors  Influencing  Pain. — Factors  influencing  the  pain  pro- 
duction are : 

(1)  Motion.  Kest  is  the  choice  of  the  patients.  They  are 
very  cautious  about  making  the  slightest  movement,  for  from 
experience  they  have  learned  that  motion  of  all  kinds  results  in 
pain.  Riding  in  springless  wagons,  jumping  and  running  are 
accompanied  by  pain;  for  the  same  reason,  rapid  walking,  jar- 
ring, and,  in  some  cases,  going  up  and  down  stairs  are  distasteful. 
After  such  movements  the  urine  is  frequently  tinged  with  blood. 
Upon  rest  and  quiet  the  pain  ceases  and  the  blood  disappears. 
Violent  or  sudden  turnings  or  twistings  of  the  body  also  cause 
pain.  If  the  stone  is  small  and  is  freely  movable,  turning  from 
side  to  side,  or  rolling  over  in  bed,  generally  causes  severe  pain. 
This  pain  is  sharp  and  burning,  and  is  frequently  referred  to 
the  anus  and  rectum.  Straining  at  stool  will  also  cause  pain. 
In  some  cases  coughing  and  deep  breathing  also  produce  pain. 

(2)  Position.  The  patient  generally  lies  upon  his  back,  since 
he  has  found  that  this  is  the  posture  of  greatest  ease. 


THE    URETHRA  695 

(3)  Digestion.  During  the  active  stage  of  digestion  pain  is 
always  greater  than  at  other  times. 

Absence  of  Pain. — Absence  of  pain  symptoms,  when  a  calcu- 
lus is  in'  the  bladder,  is  due  to : 

(1)  Anesthesia  of  the  mucous  membrane  of  the  bladder,  the 
result  of  a  cord  lesion,  such  as  tabes  dorsalis. 

(2)  Mechanical  causes  preventing  the  stone  from  falling  upon 
the  sensitive  neck  of  the  bladder,  as  (a)  its  adherence  to  the  blad- 
der walls;  (b)  sacculation  of  the  bladder  walls,  or  (c)  pouching 
of  the  bas-fond  of  the  bladder,  so  that  pressure  cannot  be  made 
upon  the  stone  by  the  contracting  bladder  walls. 

THE    URETHRA 

Pain  in  urethral  disease  follows  the  course  of  the  twelfth  dorsal 
segment  (Head).  Urethritis  will  be  considered  in  connection 
with  the  male  genitalia.  Here  will  be  considered  only  those  con- 
ditions connected  with  the  urethra  in  its  essential  relation  as  a 
urinary  organ.     These  are  caruncle  and  stone. 

Urethral  Caruncles. — Urethral  caruncles,  fouud  only  in  the 
female,  are  very  painful  to  the  touch.  They  also  give  rise  to 
very  considerable  pain  on  the  passage  of  the  urine.  This  pain 
gradually  lessens  after  the  act  until,  in  the  course  of  a  few  min- 
utes, only  a  slight  burning  or  smarting  remains.  Intercourse  may 
become  impossible  because  of  the  very  severe  pain,  or  because  of 
the  vaginismus  which  is  reflexly  produced.  In  some  patients 
friction  from  the  rubbing  of  the  clothing  or  from  the  contact  of 
adjacent  parts  may  become  so  distressing  that  moving  or  walking 
is  hardly  possible. 

However,  in  most  cases,  the  pain  is  not  so  extremely  severe. 
In  some  it  is  most  distressing,  while  in  others  it  is  of  such  a  slight 
degree  that  it  may  give  rise  only  to  a  feeling  of  discomfort. 

The  pain  is  probably  due  to  irritation  of  the  delicate  nerve 
filaments  exposed  in  the  denuded  surface  of  the  caruncle.  It  may 
also  be  due,  in  a  certain  degree,  to  the  gTeatly  increased  sensi- 
bility of  the  caruncle,  owing  to  the  increased  nerve  supply. 


696      THE  URETER,  BLADDER  AND  URETHRA 

Calculus. — The  passage  of  a  calculus  through  the  urethra  causes 
a  burniug  pain,  as  though  a  hot  iron  were  drawn  along  the  pas- 
sage. If  the  stone  is  rough  the  pain  is  much  more  severe.  At 
the  same  time  urination  is  extremely  difficult,  and  blood  is  gen- 
erally present  in  the  urine. 

Rupture  of  the  Urethra. — Rupture  of  the  urethra  in  the  mem- 
branous portion  causes  an  extravasation  of  blood  and  urine  into 
the  tissue  between  the  two  layers  of  the  triangular  ligament.  At 
the  lateral  aspect  of  this  space  are  the  dorsal  nerves  of  the  penis ; 
so  that,  when  extravasation  occurs,  pressure  is  made  upon  them 
and  the  pain  is  referred  to  the  glans  penis,  although  the  extrava- 
sated  fluid  collects  in  the  scrotum. 

Transferred  Pain  in  Urethral  Disease. — Fenwick  mentions  a 
case  of  pain  in  the  foot  due  to  stricture  of  the  urethra.  He  also 
records  another  case  of  pain  in  both  forearms  which  occurred 
during  urination.  In  this  patient  a  prostato-membranous  catarrh 
was  found.  Both  patients  were  relieved  of  the  pain  by  treat- 
ment appropriate  to  the  urethral  condition. 

Pain  on  Urinating. — Where  pain  is  felt  during  urination 
exact  information  should  be  obtained  as  to  the  exact  time  in  the 
urinary  act  at  which  it  occurs.  Pain  at  the  beginning  of  urina- 
tion, without  a  continuance  during  the  act,  generally  means  some 
obstruction  to  the  onward  flow  of  the  urine.  This  obstruction 
may  be  due  to  a  mild  urethritis,  owing  to  which  the  lumen  of  the 
urethra  is  blocked  by  shreds  of  mucopus  or  mucus;  or  it  may  be 
due  to  a  very  soft  stricture,  or  to  an  enlarged  prostate  that  at 
first  offers  some  obstruction  to  the  onward  passage  of  the  urine. 
A  clot  or  small  stone  may  lodge  in  the  opening  of  the  urethra, 
and  very  severe  pain  and  retention  of  the  urine  may  tlius  occur. 
This  pain  continues  until  the  obstruction  has  been  overcome, 
when  it  ceases  and  urination  again  becomes  free. 

If  pain  be  present  during  the  entire  time  of  the  urinary  act 
the  following  should  be  inquired  into: 

The  presence  of  irritating  constituents  in  the  urine  itself, 
such  as  phosphates,  eliminated  drugs  (cantharides),  urates,  glu- 
cose, and  various  ingested  acids.     The  burning  may  also  be  due 


THE    URETHRA  697 

to  a  too  great  concentration  of  a  normal  urine,  so  that,  owing  to 
that  concentration,  substances  which  ordinarily  do  not  irritate 
do  so  most  severely. 

This  burning  may  also  be  caused  by  inflammatory  states  (in- 
filtration, granular  patches,  etc.)  along  the  urinary  tract,  either 
in  the  prostate  or  in  the  urethra.  The  burning  sensation  in  those 
conditions  is  most  severe,  and  at  times  does  not  end  with  urina- 
tion, but  persists  some  little  period  beyond.  A  narrowed  meatus 
also  causes  pain  during  urination. 

Pain  during  urination  also  may  be  due  to  inflammatory 
changes  in  the  bladder  walls,  or  to  diseases  of  or  changes  in  the 
adjacent  organs,  such  as  anteflexion  of  the  uterus,  which  in  a 
pregnant  woman  often,  owing  to  traction  on  the  bladder,  causes 
severe  pain  during  the  urinary  act.  Abscess  in  the  prevesicular 
space  of  Douglas  and  pregnancy  itself,  by  its  pressure  on  the 
bladder,  causes  pain.  Adhesions  to  different  organs  by  the  blad- 
der are  also  a  cause  of  painful  urination,  likewise  are  tumors  of 
the  uterine  adnexa.  The  pain  in  these  various  lesions  is  probably 
due  to  the  hindrance  wdiich  they  offer  to  the  contraction  of  the 
bladder  musculature,  or  to  the  free  exit  of  urine. 

Pain  at  the  end  of  urination  is  due  to  prostatitis,  urethritis, 
or  to  some  disease  in  the  bladder.  At  this  time  the  bladder  walls 
close  down,  pressure  is  made  upon  the  trigone,  and,  if  pain  is 
present,  it  generally  indicates  an  inflammation  of  the  bladder 
wall  or  the  presence  of  a  calculus,  which  drops  or  is  pushed  into 
the  triangular  opening  at  the  beginning  of  the  ureter  terminals, 
and  thus,  by  pressing  upon  the  irritated  surfaces,  causes  pain. 
This  pain  is  most  excruciating.  It  frequently  causes  the 
patient  again  to  attempt  to  urinate,  even  though  the  act  has  just 
been  performed.  Should  the  pain  be  present  all  through  the  act, 
and  be  continued  beyond,  as  a  dull,  aching  sensation  in  the  rec- 
tum, it  indicates  that  the  prostate  is  probably  at  fault. 

Pain  continuing  beyond  the  urinary  act  may,  in  some  cases,  be 
due  to  urethral  changes,  as  a  blocking  from  a  calculus,  or  a  growth 
at  the  vesicular  orifice,  closing  the  urethra, 


CHAPTER   XXXT 

THE  MALE  ORGANS  OF  GENERATION 

The  male  organs  of  generation  are  the  testicles,  epididymis, 
vas  deferens,  seminal  vesicles,  prostate,  and  penis. 

THE    TESTICLES 

The  testicles,  when  intlamed,  become  very  tender,  especially 
to  deep  pressure.  In  testicular  affections  the  skin  of  the  scrotum 
is  not  necessarily  tender,  the  testicles  and  scrotum  being  supplied 
by  entirely  different  nerves.  The  stroma  of  the  testicle  receives 
its  nerve  supply  principally  from  the  sympathetic  segments,  while 
the  skin  of  the  scrotum  is  supplied  by  the  genital  branch  of  the 
genitocrural.  Irritative  lesions  of  the  testicle  cause  referred 
aching  or  discomfort  in  the  reference  areas  (deep  pres- 
sure sensibility)  of  the  eleventh  and  twelfth  dorsal  segments. 
Pain  sensibility  in  the  testicle  is  also  conveyed  through  the 
genital  branch  of  the  genitocrural  nerves.  The  testicle  and  its 
coverings  being  supplied  by  different  nerves,  irritation  of  the 
different  structures  will  produce  pain  in  different  areas,  but  al- 
ways in  the  area  with  which  they  have  nerve  connections.  After 
the  testicle  has  descended  into  the  scrotum,  the  communication 
between  the  testicular  sac  and  the  j)eritoneum  becomes  abolished, 
and  the  testicle  lies  in  a  closed  sac. 

The  deep  pressure  pain  produced  in  testicle  disease  is  due  to 
distention  of  the  capsule.  It  is  a  type  of  sensibility  quite  similar 
to  that  found  in  other  viscera.  Should  the  distention  be  gradual 
pain  may  be  entirely  absent.  In  some  cases  the  testicle  grows  to 
a  great  size,  and  does  not  produce  any  inconvenience  other  than 
the  dragging  due  to  its  overAveight. 

The  testicle  is  capable,  however,  of  giving  rise  to  severe  pain 
698 


EPIDIDYMIS,  VAS  DEFERENS,  AND  SEMINAL  VESICLES    699 

when  inflammation  causes  it  to  become  greatly  enlarged.  At  such 
a  time  it  is  very  painful  and  is  extremely  tender.  Pressure  on 
it  causes  pain  referred  to  the  inguinal  region  and  the  inner  side 
of  the  thigh.  In  some  cases  it  may  be  reflected  to  the  back  or  to 
the  iliolumbar  region. 

Trauma  of  the  testicle  may  or  may  not  be  very  painful.  In 
a  case  of  Mitchell's  a  wound  of  the  testicle  caused  pain  in  the 
back  alone.  The  deep  pressure  sensibility  of  the  testicle  has  a 
peculiar  quality,  in  that  it  is  often  associated  with  nausea  and 
vomiting. 

EPIDIDYMIS,  VAS  DEFERENS,  AND  SEMINAL  VESICLES 

The  genital  ducts  are  the  epididymis,  the  vas  deferens,  with 
the  seminal  vesicle  as  a  reservoir. 

In  a  comj)licated  urethritis  all  of  these  may  become  involved, 
and  gTeat  inconvenience  may  result.     Yet  pain  is  not  a  promi- 


FiG.  165. — Areas  of  Cutaneous  Tenderness  in  Disease  of  the  Epi- 
didymis. 
A  and  B  correspond  to  the  points  of  maximum  tenderness  of  the  11th  dorsal 

segment.    B  and  C  correspond  to  the  points  of  maximum  tenderness 

of  the  12th  dorsal  segment. 


nent  symptom  until  the  inflammation  extends  far  enough  to 
involve  the  epididymis.  Then  it  is  most  severe,  and  is  of  a 
throbbing,  aching  character  and,  because  of  the  increased  blood 
stasis,  is  most  intense  in  a  standing  position.  The  epididymis,  at 
the  same  time,  is  exquisitely  tender  to  the  touch,  and  pressure 


700       THE  MALE  ORGANS  OF  GENERATION 

upon  it  produces  the  peculiar  sickening  sensation  that  is  as- 
sociated with  deep  pressure  on  the  testicle.  Pain  when  pres- 
ent radiates  anteriorly  into  the  distribution  area  of  the  crural 
branch  of  the  genitocrural  ner^^e,  and  posteriorly  over  the  lower 
lumbar  and  the  upper  sacral  vertebrae,  which,  according  to  Head, 
are  the  areas  of  the  eleventh  and  twelfth  dorsal  segments.  The 
pain  may  also  be  felt  in  the  leg,  as  far  down  as  the 
knee,  and  in  the  perineum.  Figure  165  illustrates  the  places  where 
cutaneous  tenderness  is  generally  found  in  inflammation  of  the 
epididymis. 

THE  PROSTATE 

The  prostate  is  the  principal  seat  of  pain  in  all  acute  infec- 
tions of  the  male  genital  tract.  Ordinarily  the  passage  of  the 
urinary  stream  over  it  is  without  pain,  but  when  the  urethral 
surface  is  inflamed,  the  subepithelial  tissue,  becoming  congested, 
swells  and  blocks  the  urethra.  The  urinary  stream  now  causes  a 
sudden  separation  of  the  urethral  surfaces  and  compression  of 
the  tender  tissues,  with  consequent  pain  production.  This  pain 
is  most  marked  in  the  beginning,  and  persists  during  the  entire 
urinary  act,  and  continues  for  some  short  time  thereafter.  If 
the  portion  of  the  gland  under  the  bladder  wall  is  affected,  and 
the  inflammation  is  communicated  to  the  mucous  membrane  of 
the  trigone,  frequency  of  urination,  with  severe  pain  at  the  end 
of  the  urinary  act,  comes  on.  Likewise,  if  that  part  of  the  pros- 
tate adjacent  to  the  rectum  is  involved,  defecation  becomes  very 
painful.  Abscess  of  the  gland  in  any  of  these  regions  acts  about 
the  same  as  does  an  inflammation,  but  has  symptoms  of  much 
greater  intensity.  In  prostatic  involvement  referred  pain  may 
also  be  present  in  the  perineum  (through  the  perineal  nerves) 
and  in  the  back  and  down  the  legs  (because  of  the  intimate  as- 
sociation between  the  roots  of  the  pudic  nerve  with  the  sacral 
and  lumbar  plexi)   (Bryant,  895). 

Congestion  and  Inflammation. — Congestion  of  the  prostate 
occurs  at  times  without  inflammation, .  and  is  found  especially 
in  those  indulging  in  sexual  excesses.     The  sensation  complained 


THE  PROSTATE 


701 


of  is  more  of  an  aching  or  dragging  across  the  back  in  the  lumbar 
region  than  an  actual  pain. 

However,  both  congestion  and  inflammation  cause  in  the  glans 
penis  a  pain  not  relieved  by  micturition.  This  glans  pain  is  of 
the  referred  variety,  the  stimuli  being  transmitted  through  the 
dorsal  nerve  of  the  penis,  a 
branch  of  the  pudic  supplying 
the  prostate.  The  pudic  also 
sends  a  branch  to  supply  the 
perineum  and  the  anus,  and  in 
both  these  regions  referred 
pain  may  be  felt. 

Lesions — Lesions  of  the 
prostate  may  also  cause  re- 
flected pain  and  hyperalgesia 
in  the  tenth  and  eleventh  dor- 
sal, the  first,  second,  and  third 
sacral,  and  sometimes  also  in 
the  first  lumbar  visceral  seg- 
ments. The  areas  of  distribu- 
tion of  these  segments  are  illus- 
trated in  the  accompanying 
figure. 


Fig.  166. — Areas  of  Distribution 
OF  THE  10th  and  IIth  Dorsal 
Segments,  and  the  1st,  2d,  and 
3d  Sacral  Segments  on  the 
Right  Side. 

These  areas  are  most  frequently 
involved  in  prostatic  disease. 
(Head,  Brain,  Vol.  XVI,  p.  85.) 


In  some  cases  also  the 
prostate  may  make  pressure 
on  the  sciatic  nerve  and  thus 
cause  pain  which  is  referred 
to  its  distribution  area. 

The  most  common  diseases 
of  the  prostate  causing  pain  are:      (1)   congestion,    (2)    inflam- 
mation, (3)  hypertrophy,  (4)  new  growths. 

Hypertrophy. — Congestion  and  inflammation  have  been  con- 
sidered. ISText  and  closely  related  to  these  two  is  hypertrophy. 
Generally  it  is  wathout  pain,  or,  in  fact,  symptoms  of  any  kind, 
unless,  owing  to  increase  in  size,  the  prostate  encroaches  upon 
the  neighboring  structures  and  causes  some  functional  disturb- 


702  THE   MALE    ORGANS    OF    GENERATION 

ance.  For  instance,  no  pain  is  felt  in  median  lobe  enlargement 
until  the  enlarged  lobe  causes  retention  of  urine,  with  infection 
and  consequent  cystitis.  Then  the  paii-.  becomes  most  severe,  but 
it  is  not  the  pain  of  the  hypertrophy,  but  of  the  cystitis.  Hyper- 
trophy of  the  prostate  may  cause  pain  in  almost  any  region,  de- 
pending upon  the  changed  relationships,  pressure,  etc.,  which 
are  produced  in  the  neighboring  structures.  Some  of  the  places 
where  pain  is  felt  are  the  glans  penis,  the  back,  the  hips,  the 
buttock,  down  the  thigh  and  legs,  the  foot,  and  the  suprapubic 
and  perineal  regions. 

Tumors  of  the  Prostate. — The  most  common  is  cancer.  In 
it  prostatic  pain  may  be  complained  of  only  when  the  bladder  is 
distended  with  urine.  As  a  general  rule,  in  the  soft  varieties 
of  cancer,  pain  is  not  a  prominent  symptom.  It  is  usually  only 
when  the  cancer  is  hard  and  the  surrounding  tissues  become  infil- 
trated that  pain  and  discomfort  ensue.  In  some  cases,  in  which 
the  cancer  involves  the  vesicoprostatic  portion  of  the  bladder,  pain 
of  a  spasmodic  type  occurs.  It  depends  for  its  production  upon 
the  compression  of  the  nerve  filaments  in  the  muscular  walls  of 
the  bladder,  particularly  so  if  the  lesion  occurs  in  the  vicinity  of 
or  involves  the  vesical  sphincter. 

Tuberculosis. — Tuberculosis  of  the  gland  structure  is  not  pain- 
ful unless  neighboring  tissues  are  involved.  Calculi,  likewise,  may 
be  present  in  the  prostate  without  causing  pain. 

Associated  Symptoms. — Associated  symptoms  of  prostatic  in- 
volvement are: 

(1)  Frequency  of  urination.  This  is  one  of  the  most  charac- 
teristic symptoms.  Commonly,  when  the  prostate  is  not  acutely 
inflamed,  urination  is  frequent,  but  is  entirely  free  of  pain. 

(2)  On  passing  a  sound  the  most  extreme  agony  is  experi- 
enced by  the  patient  as  it  passes  over  the  prostatic  portion  of  his 
urethra. 


THE   PENIS  703 


THE   PENIS 


Pain  felt  in  the  penis  may  originate  from  conditions  present 
in  its  substance,  involving  principally  the  uretlira,  or  it  may 
be  referred  from  distant  lesions. 

Urethritis. — The  lesion  of  the  penis  causing  the  most  pain  is,  in 
the  vast  majority  of  cases,  an  acute  inflammation,  generally  gon- 
orrheal, of  the  urethra.  Inflammation  of  the  urethra  causes  pain 
in  urination,  which,  however,  is  more  of  a  burning  sensation,  or, 
as  some  of  the  i^atients  put  it,  "a  feeling  as  though  they  were 
passing  hot  oil,"  than  an  actual  pain.  The  irritation  is  often 
transmitted  to  the  head  of  the  penis,  where  it  is  felt  as  a  severe 
stabbing.  When  the  urethra  and  adjacent  tissues  are  inflamed 
erection  causes  acute  pain.  Owing  to  the  structure  of  the  penis 
inflammation,  when  the  spongy  body  only  is  involved,  causes  it, 
during  erection,  to  be  bent  on  itself.  Many  misguided  individ- 
uals, ignorant  of  the  true  nature  of  tlie  pain  production,  have 
attempted  forcible  straightening  of  the  penis  in  such  conditions, 
with  resulting  rupture  of  the  urethra. 

Referred  pains  felt  in  the  penis  may  originate  in  lesions  of 
the  kidneys  or  ureters,  in  prostatic  diseases,  in  some  spinal  cord 
conditions,  and  occasionally  from  rectal  disorder. 

Inflammation  of  the  prepuce  (balanitis)  causes  a  pain  that  is 
especially  marked  on  erection  of  the  penis.  In  the  state  of  erec- 
tion the  prepuce  is  stretched,  normally,  without  any  special  sen- 
sation, but  should  it  be  inflamed,  pain  results.  Pain  is  also  pro- 
duced by  the  rubbing  of  the  clothing  against  the  inflamed  and 
eroded  surfaces. 

Inflammation  of  Cowper's  Glands. — Sometimes  the  glands  in 
the  bulbo-membranous  urethra,  known  as  Cowper's  glands,  become 
inflamed.  When  they  do,  pain  is  felt  in  the  perineum,  where, 
on  palpation,  a  painful  mass  may  be  palpated.  The  pain  is 
greatly  increased  by  motion,  such  as  walking;  defecation  and  the 
sitting  posture  also  increase  the  jiain,  which  is  of  a  throbbing 
character.  To  cause  this  throbbing  it  is  not  necessary  that  the 
congestion  be  severe,  for  the  glands  lie  between  the  two  layers  of 


704  THE   MALE    ORGANS    OF    GENERATION 

the   triangular  ligament  and  are  inclosed  in  perineal  fascia,  so 
that  the  least  engorgement  is  resisted,  and  gives  rise  to  pain. 

The  glans  penis  itself,  generally,  is  not  painful.  Examples 
of  an  ulcer  of  the  glans  being  present  without  the  patient's 
knowledge  are  common.  Indeed,  he  may  not  be  aware  of  any- 
thing abnormal  until  the  skin  is  involved,  or  until  lymphangitis 
or  lymphadenitis  occurs.  However,  the  penis  is  not  absolutely 
without  sensation,  for  it  is  capable,  probably  more  so  than  ordi- 
nary organs,  of  appreciating  different  degrees  of  pressure. 
(Head  and  Kivers,  86,  p.  39.) 


CHAPTEK  XXXII 

PAIN  IN  THE  FEMALE  GENITALIA 
GENERAL    CONSIDERATIONS 

Anatomy. — The  female  genitalia  consist  internally  of  tlie 
uterus,  Fallopian  tubes,  and  the  ovaries,  and  externally  of  the 
vagina.  The  internal  organs  lie  deep  in  the  pelvis,  and  are 
protected  against  traumatism  by  the  bony  wall  which  surrounds 
them.  This  wall,  although  it  serves  the  purpose  of  a  protection 
to  the  sexual  organs  at  the  times  when  the  organs,  enlarging  for 
some  reason,  cannot  accommodate  themselves  without  making 
pressure  on  the  surrounding  structures,  also  is  a  cause  of  pain  and 
distress.  The  free  mobility  of  the  uterus  and  adnexa  helps  to 
overcome,  in  a  measure,  the  structural  disadvantages  of  its  loca- 
tion. 

The  peritoneum,  which  covers  the  uterus,  tubes,  and  ovaries, 
is  reflected  over  the  anterior  and  posterior  surfaces  of  these  or- 
gans, and  on  either  side  forms  the  two  layers  of  the  broad  liga- 
ment. The  uterus  lies  in  front  of  the  rectum  and  posterior  to 
the  urinary  bladder.  Any  enlargement  or  distention  of  the  rec- 
tum causes  a  displacement  of  the  uterus,  raising  it  up  and  throw- 
ing it  forward.  Normally  this  causes  no  discomfort,  but  when 
inflammation,  with  its  accompanying  adhesive  formations,  arises, 
this  free  mobility  is  curtailed,  and  change  of  position  causes  pain. 
Owing  to  the  close  anatomical  connection  and  relationship  of  the 
uterus  with  adjacent  organs,  any  inflammation  or  derangement 
of  the  economy  of  these  organs  has  an  unfavorable  influence  upon 
the  uterus,  either  through  the  nervous  system  or  the  circulatory 
supply,  and  may  lead  to  pain  production. 

Nerve  Supply. — The  female  genitalia  receive  their  nerve  sup- 

705 


706 


PAIN   IN   THE   FEMALE    GENITALIA 


gu 


ply  from  both  the  sympathetic  and  the  cerebrospinal  systems,  the 
sympathetic  being  distributed  to  the  upper  part  of  the  uterus,  the 
tubes  and  the  ovaries,  and  the  upper  part  of  the  vagina,  while  the 
cerebrospinal  nerves  are  distributed  to  the  lower  uterine  segment 
and  the  vagina.  The  ovaries  and  tubes  are  supplied  entirely 
by  the  sympathetic,  the  nerves  supplying  the  ovary  and  the  distal 

extremity  of  the 
tubes  being  derived 
from  the  ovarian 
plexus,  which,  in 
turn,  receives  its 
fibers  from  the 
fourth  and  fifth  lum- 
bar ganglia  of  the 
sympathetic.  The 
proximal  end  of  the 
tube  and  the  upper 
part  of  the  uterus  re- 
ceive their  supply 
from  the  uterine 
plexus,  and  this  also 
derives  most  of  its 
fibers  from  the 
fourth  and  fifth  lum- 
bar ganglia  of  the 
sympathetic. 

At  this  point  it  is 
well  to  recall  that  the 
lumbar  ganglia  do 
not  corresjiond  with  the  lumbar  visceral  segments  of  the  cord,  as 
described  by  Head.  The  nerves  which  pass  through  the  ganglia 
may  arise  from  much  higher  segments  of  the  cord  than  the  ganglia 
through  which  they  pass  would  seem  to  indicate.  The  segmental 
supply  will  be  considered  on  p.  713. 

To  understand  better  the  nerve  supply  of  the  female  genitalia 
each  organ  will   be   considered   separately.      The   supply  to   the 


Fig.  167. — Nerve  Supply  of  Female  Genitalia. 

cu,  spinal  uterine  center;  plh,  hypogastric 
plexus;  nhy,  hypogastric  nerve;  npc,  nerves 
pudendres  communis;  nh,  hemorrhoidal  nerves; 
gu,  peripheral  ganglion  in  vaginal  form;  s, 
vagina;  vu,  bladder;  vl,  vulva;  an,  anus. 
(Bechterew's  "Functionen  der  Nervencen- 
tren.") 


GENERAL    CONSIDERATIONS  707 

ovaries  and  tubes  will  first  be  traced,  and  then  the  supply  to  the 
uterus  and  vagina. 

The  ovaries  are  probably  supplied  entirely  by  sympathetic 
fibers  (Luschka,  Van  Hoerff),  which  are  derived  from  a  plexus 
surrounding  the  ovarian  artery.'  This  plexus,  in  turn,  is  formed 
by  nerves  from  the  renal  and  aortic  plexi,  and  thus  is  in  inti- 
mate connection  with  the  abdominal  sympathetic ;  so  that  any  de- 
rangement of  the  ovaries  may  produce  sympathetic  disturbance! 
in  the  abdominal  viscera.  The  plexus  surrounding  the  ovarian 
artery  sends  fibers  into  the  ovary,  to  form  plexi  surrounding 
the  larger  blood  vessels.  A  plexus  is  also  formed  in  the  cortex 
and  sends  nerves  to  the  periphery,  to  end  on  the  surface  between 
the  germinal  epithelial  cells,  or  in  the  follicles,  where  they  termi- 
nate in  the  walls  of  the  blood  vessels.  Xone  of  the  fibers  pene- 
trate beyond  the  theca.  In  opposition  to  the  view  that  the  ovaries 
are  supplied  entirely  by  sympathetic  fibers  is  that  of  Head  and 
Kivers  (86),  who  hold  that  the  ovary  receives  a  part  of  its  nerve 
supply  from  the  abdominal  wall,  its  innervation  probably  being 
connected  with  the  last  dorsal  and  first  lumbar  nerves.  However, 
this  is  likely  true  only  of  the  peritoneal  covering  which  the  ovary 
has  acquired  during  its  developmental  descent,  for  in  early  fetal 
life  it  lies  close  to  the  abdominal  wall,  beneath  the  peritoneum. 

The  Fallopian  tubes  receive  their  nerve  supply  from  the  sym- 
pathetic. The  nerves  follow  the  arteries  and  reach  the  tubes  from 
the  ovarian  and  uterine  plexi  (cervical  and  corporal).  After 
reaching  the  tubes  the  nerve  fibers  penetrate  into  the  peritoneum 
and  immediately  beneath  it  form  a  plexus  (the  subserous),  from 
which  some  nerves  are  given  off  to  supply  the  muscular  tissues, 
and  others  to  form  a  subepithelial  plexus,  which  lies  in  and 
supplies  the  mucous  membrane. 

The  uterus  is  supplied  both  by  the  sympathetic  and  the  cere- 
brospinal systems.  The  sympathetic  is  distributed  chiefly  to  the 
body  of  the  uterus  and  is  formed  into  two  plexi,  the  smaller  of 
which  lies  upon  the  upper  and  lateral  surface  somewhat  pos- 
teriorly, and  is  distributed  to  the  posterior  and  lateral  surfaces 
of  the  uterus.     The  larger  is  distributed  to  the  cervix  and  the 


708  PAm   m   THE   FEMALE   GENITALIA 

vaginal  vault.  One  of  these  ganglia  is  especially  large,  and  is 
called  the  cervical  ganglion.  It  lies  behind  and  to  the  side  of 
the  cervix.  The  uterus,  in  addition  to  the  sympathetic  fibers,  re- 
ceives medullated  fibers  from  the  second,  third,  and  fourth  sacral 
nerves^  (third  and  fourth  sacral,  Xovak),  which  also  supply  the 
vagina,  and,  through  the  pudic,  are  distributed  to  the  perineum 
and  the  bladder.  Therefore,  when  the  lower  uterine  segment  is 
affected,  pain  may  be  felt  in  the  bladder  and  the  perineum. ^ 

In  the  uterus  the  course  of  the  sympathetic  and  spinal  nerve 
fibers  is  different,  the  sympathetic  fibers  being  distributed  to  the 
blood  vessels,  while  the  spinal  fibers  terminate  between  the  muscle 
bundles  and  in  the  mucosa  (Piersol),  but  are  probably  not  found 
above  the  cervix.  It  is  because  of  the  intimate  relationship  of 
the  cerebrospinal  fibers  to  the  uterine  musculature  that  uterine 
spasm  is  so  specifically  localized  to  the  uterus  ;^  because,  when 
the  uterus  contracts,  the  nerve  filaments  are  caught  between  the 
individual  muscle  bundles  and  are  tightly  squeezed.  This  irri- 
tation produces  the  sensation  peculiar  to  the  uterine  contraction^, 
and  is  called  uterine  "colic." 

The  nerves  of  the  uterus  show  great  ability  to  adapt  them- 
selves to  changes  in  size  of  the  uterus.  This  is  well  seen  during 
pregnancy,  when  the  uterus  enlarges  to  many  times  its  normal 

1  Bechterew,  quoting  from  Rein  and  Pisemsky. 

2  According  to  v.  Basch  and  Hofman  (379),  there  are  two  sets  of  nerves 
in  the  uterus:  the  nervi  uterini,  reaching  the  uterus  by  way  of  the  hypogastric 
and  sympathetic  nerves,  and  the  nervi  uterini  sacralis,  passing  from  the  main 
sympathetic  chain,  and  belonging  to  the  pelvic  splanchnics  (Korner,  Robling, 
378).  The  stimulation  of  the  hypogastric  nerve  causes  a  contraction  of  the 
circular  muscles  of  the  uterus.  Stimulation  of  the  cerebrospinal  nerves  causes 
the  longitudinal  to  contract. 

3  Since  the  stimuli  carried  to  the  brain  over  cerebrospinal  tracts  are 
definitely  localized  to  the  area  in  which  they  are  produced,  any  stimuli 
occurring  in  the  spinal  nerves  supplying  the  uterus  would  be  referred 
to  the  area  in  which  they  are  produced,  viz.,  in  the  lower  uterine  segment. 
The  localization  of  the  pain  is  not  as  definite  as  it  would  be  if  some  of  the 
somatic  nerves  were  involved,  for  one  of  the  chief  functions  of  the  somatic 
nerve's  is  to  interpret  pain,  while  those  of  the  uterus  are  concerned  more  with 
nutrition  and  muscular  tone.  So  that  pain  stimuli  present  in  the  nerves 
supplying  the  uterus  are  not  interpreted  definitely  as  coming  from  the  uterus, 
but  are  referred  to  the  area  of  distribution  of  the  pudic,  one  of  the  functions 
of  which  IS  to  transmit  pain  sensation. 


GENERAL    COXSIDERATIONS  709 

size.  The  nerves  increase  in  size  but  not  in  number.  The  gan- 
glia also  increase  in  size ;  naturally  they  will  be  somewhat 
stretched,  and  this  stretching  produces  irritation,  which  is  trans- 
mitted to  the  cord,  and  is  reflexly  felt  as  a  pain  or  aching  in 
the  back  or  dowTi  the  thighs  in  the  area  of  distribution  of  the  cord 
zones  connected  with  the  uterus. 

The  sensibility  of  the  uterus,  ovaries,  and  tubes  to  ordinary 
stimuli  is  very  slight,  if  it  is  present  nt  all,  so  that,  on  exposure, 
during  operation  (cocain  anesthesia),  a  normal  ovary  can  be 
pinched  w4th  a  clamp  or  a  mouse-tooth  forceps  without  the  pa- 
tient's knowledge.  The  same  can  be  done,  in  the  majority  of 
cases,  with  normal  tubes  (Sampson,  Meyers,  152,  p.  7i9).  Deep 
pressure  upon  an  ovary  produces  that  peculiar  sickening  sensa- 
tion so  familiar  in  the  male  when  the  testicles  are  squeezed. 
Some  women  are  more  sensitive  to  ovarian  pressure  than  are 
others.  Intrapelvic  manipulation  is  usually  less  painful  iii 
women  past  the  menopause,  and  also  less  painful  in  those  who 
have  borne  children.  Most  observers  agree  that  the  uterine, 
tubal,  or  ovarian  peritoneum  is  not  very  sensitive  to  traction, 
to  pressure,  or  to  gauze  rubbing  against  it,  but  that  the  parietal 
abdominal  peritoneum  is  most  sensitive  to  these  same  stimuli. 

The  cervix  uteri  is  insensitive  to  touch,  but  is  very  sensitive  to 
crushing  or  dilatation.  The  endometrium  is  as  a  rule  without 
pain  sensation  (Xovak),  though  when  inflamed  it  may  give  rise 
to  a  sensation  of  weight  and  heaviness.  In  this  condition  intra- 
uterine points  or  areas  of  tenderness  may  develop  (see  under 
Uterus) . 

Diagnosis  of  Pelvic  and  Hysterical  Pain. — Pelvic  Pain. — If 
the  patient  complains  of  pain,  and  pelvic  disease  is  suspected  as  a 
cause,  inquiry  should  be  made  as  to  the  periodicity  of  the  pain, 
its  exact  location,  its  relationship  to  the  menstrual  period,  and  the 
history  of  past  diseases.  If  such  inquiry  is  made,  it  will  be 
found  that  pain,  if  it  is  due  to  pelvic  lesions,  will  have  some  or 
all  of  the  following  characteristice : 

(1)  It  is  either  constant,  with  periodic  exacerbations  corre- 
sponding to  the  menstrual  period,  or  is  present  only  at  the  time 


710  PAIN   IN    THE   FEMALE    GENITALIA 

of  menstruation;  (2)  it  is  felt  in  the  lower  abdomen  and  radiates 
to  the  back  or  lower  limbs,  or  it  is  felt  in  the  right  or  left  iliac 
region;  (3)  it  is  associated,  in  quite  a  fair  proportion  of  cases, 
with  a  tender  point  one  to  one  and  one-half  inches  below,  and 
three-quarters  of  an  inch  internal  to,  the  umbilicus  (Morris's 
point). 

In  regard  to  the  anamnese,  careful  questioning  of  these 
patients  will  generally  elicit  the  fact  that  at  some  time  in  the 
past  they  have  suffered  from  parametritic  inflammation.  Yet 
great  care  must  be  exercised  in  judging  of  the  value  of  subjec- 
tive symptoms,  as  given  by  the  patient,  for,  at  the  present  time, 
because  of  the  prevalence  of  pelvic  diseases,  and  the  diffusion  of 
knowledge  concerning  their  symptoms,  it  frequently  happens  that 
a  hysterical  patient  will  simulate  a  uterine  or  ovarian  disorder 
so  closely  that  it  is  very  difficult  to  make  a  diagnosis. 

However,  in  nearly  all  cases  a  fairly  positive  diagnosis  can 
be  made,  for,  as  Eulenberg  says  (145,  pp.  1274-1275)  :  "Spon- 
taneous recurring  pains  in  the  inner  or  outer  genitalia  (in  the 
pelvis,  coccyx,  or  abdominal  wall),  when  they  are  the  exclusive 
or  predominating  symptom,  if  they  occur  without  positive  organic 
findings,  independently  of  the  quality,  intensity,  persistency,  and 
former  quality  of  the  pain,  speak  first  against  the  acceptance  of 
a  genuine  local  disease,  and  eventually  for  a  clear  nervous  cause, 
in  the  sense  of  neurasthenia  or  typical  pain  of  psychical  hysteria. 

"In  any  case  spots,  painful  upon  pressure,  can  only  be  re- 
garded as  affections  of  genuine  genital  suffering  if  they  can  be 
referred  back  to  a  local  change ;  for  instance,  to  enlargements  of 
the  ovaries,  or  to  parametritis.  Should  the  pain,  present  on  pres- 
sure, remain  ip.  the  same  place,  on  the  same  side,  and  exist  at 
certain  periods  (menstruation)  organic  lesions  are  indicated, 
while  vacillation,  irregularity,  changes  of  the  kind  of  pain  occur- 
ring periodically,  and  resistance,  point  on  the  contrary  to  the 
neuropathic  causes." 

Hysterical  Pain. — When  pain  is  present  in  the  ovarian  re- 
gion, hysteria  should  be  considered  as  a  cause ;  the  hysterical 
origin  of  the  pain  may  be  proven  by  finding  pressure  points  on 


GENERAL    CONSIDERATIONS 


711 


other  parts  of  the  body  (Windscheid,  148,  p.  484).  Another 
point  which  aids  in  diagnosing  hysterical  pains  is  that  they  bear 
no  relation  to  sensory  nerve  distribution,  nor  to  segmental  cord 
distribution  (Dercum,  150,  p.  849). 

Another  point  aiding  in  the  diagnosis  is  that  pain  due  to 
hysteria  does  not,  as  a  rule,  subside  upon  rest  in  bed,  while  pain 
due  to  inflammatory  disease  of  the  pelvic  organs  usually  does. 
This  is  not  invariably  so,  because  many  cases  of  hysteria  and 
neurasthenia  are  greatly  benefited  by  rest  in  bed,  owing  to  the 
improvement  in  the  general  health  which  then  ensues  (Rothrock). 
In  hysteria,  also,  there  is,  as  a  rule,  diminution  or  absence  of 
the  conjunctival  and  pharyngeal  reflexes  (Windscheid).  Hysteri- 
cal  (or  neurasthenic)   pain  is  confined  to  the  left  side.     In  hys- 

DIAGNOSIS  OF  PELVIC    FROM  HYSTERICAL  PAIN 


Symptoms 

Pelvic  Disease 

Hysterical  Pain 

Pain. 

Has   definite   location   and 
remains    constant    in    this 
location.     It  makes  no  dif- 
ference   whether    the    pa- 
tient's attention  is  attracted 
elsewhere  or  not;  pressure 
over  the  site    of   the  pain 
wiU  produce   an  exacerba- 
tion   of    it.     Menstruation 
usually  influences  the  pain, 
generally  increasing  it. 

Has  no  definite  location, 
but  flits  from  one  place  to 
another.  Pain  often  is  of 
a  burning  character.  Fre- 
quently, when  the  patient's 
attention  is  attracted  else- 
where, severe  pressure  can 
be  made  over  the  indicated 
site  of  the  pain  without 
initiating  it  if  it  is  not  pres- 
ent or  without  increasing  it 
if  it  is  present.  Menstrua- 
tion usually  has  no  influ- 
ence on  the  pain. 

Fever. 

May   be  present   in   acute 
disease. 

None. 

Leukocytes. 

May  be  increased  in  acute 
attacks. 

No  increase. 

History. 

Generally     of     gonorrheal, 
tubercular,  or  puerperal  in- 
fections,  pelvic  tumors,  or 
of  pelvic  traumatism. 

No  history  of  gonorrhea, 
etc.,  but  one  of  neurosis. 

Reflexes. 

Conjunctival   and   pharyn- 
geal present. 

Conjunctival  and  pharyn- 
geal absent. 

Areas  of  hyperes- 
thesia. 

Absent. 

Present. 

712  PAIN   IN    THE   FEMALE    GENITALIA 

teria  (neurasthenia  also)  there  seems  to  be  a  lessened  resistance 
to  pain  production  in  lesions  of  the  female  genitalia.  This 
causes  them  to  react  much  more  strongly  than  normal  to  the 
slightest  irritation  (Dercum,  347;  Herman,  316);  so  that  when 
the  pelvic  disease  has  produced  a  secondary  neurasthenia  or 
hysteric  weakness  the  pain  may,  after  removal  of  the  cause  which 
has  originally  produced  it,  persist  and  be  renewed  on  the  slightest 
stimulus  arising  from  causes  which,  in  a  normal  state,  would  not 
produce  even  a  discomfort.^ 

As  an  aid  in  the  diagnosis  of  these  conditions  a  diagnostic 
chart  is  given  on  page  711. 

Varieties  of  Pain. — In  some  patients  a  long-continued  lesion 
has  produced  so  much  disturbance  in  the  nervous  system  that  a 
permanent  state  of  nerve  weakness  has  occurred,  and  the  jDatient 
suffers  from  the  condition  termed  neurasthenia.  She  is  now 
particularly  unfortunate,  for  her  years  of  suffering  have  so  re- 
duced the  resistance  of  the  nervous  system,  and  the  pathways  for 
pain  have  been  so  well  defined,  that  irritations,  even  those  of  the 
least  magnitude,  are  interpreted  as  painful.  It  should  not  be  for- 
gotten, however,  that  the  term  ^'female  complaint"  is  often  used 
as  a  subterfuge  for  weak,  irresolute,  or  lazy  souls  to  indulge  their 
innate  propensities  for  idleness. 

So  far  we  have  been  speaking  of  pain  and  painful  areas,  not 
specifying  definitely  their  location,  and  therefore  before  we  ad- 
vance further  it  will  be  well  to  consider  more  exactly  the  limits 
of  these  areas  in  which  pelvic  pain  is  felt. 

In  doing  so,  it  is  again  necessary  to  draw  attention  to  the 
fact  already  stated  that  the  j^elvic  viscera,  unlike  most  of  the 
other  abdominal  viscera,  have  two  sources  of  nerve  supply:  the 
sympathetic  and  the  cerebrospinal.  The  cerebrospinal  system, 
as  is  known,  refers  all  its  irritations  to  the  peripheral  distribu- 
tion of  the  particular  nerves  concerned,  while  the  sympathetic 
carries  the  stimulus  to  its  centers  in  the  cord.  Here  the  irrita- 
tion is  communicated   to   adjacent  centers  of  the  cerebrospinal 

1  According  to  Fritsch  (348),  pelvic  pain  persists  in  33  per  cent,  of  the 
cases  after  corrective  operations. 


GENERAL    CONSIDERATIONS  713 

system,  by  which  it  is  relayed  to  the  brain,  where  it  is  perceived 
as  coming  from  the  peripheral  distribution  area  of  the  nerves 
connected  with  these  centers.  Tims  the  pains  due  to  cerebrospinal 
irritation  are  more  apt  to  have  an  exact  orientation  than  those 
due  to  irritation  of  the  sympathetic  system.  This  is  exemplified 
in  uterine  muscle-contraction  pain,  where  the  localization  is  some- 
what exact  and  the  pain  is  of  considerable  magnitude,  because  it 
is  due  to  cerebrospinal  involvement;  while  in  endometritis,  the 
l^ain,  when  present,  is  indefinitely  placed  in  the  lower  abdomen, 
is  referred  to  the  back,  to  the  hips,  or  to  the  lower  limbs,  and  is 
of  less  intensity,  being  more  of  an  aching  than  a  pain,  because 
it  is  of  sympathetic  origin. 

The  sympathetic  supply  of  the  body  of  the  uterus  seems  to  be 
from  the  tenth,  eleventh,  and  twelfth  dorsal  segment  [first  or  first 
and  second  lumbar  (Donald  and  Lickley)],  while  the  lower  uterine 
segment  is  supplied  by  the  third  and  fourth  lumbar,  and  some- 
times the  first  and  second  sacral  segments  [second,  third,  and 
fourth  sacral  (Donald  and  Lickley)].  In  this  connection  it  is 
always  well  to  remember  that  the  sacral  segments  do  not  by  any 
means  correspond  to  the  sacral  nerves.  The  sacral  segments  are 
concerned  principally  with  the  dilatation  of  the  cervix,  such  as 
occurs  in  the  first  stages  of  labor,  while  the  dorsal  segments  are 
concerned  principally  with  the  contraction  of  the  uterus.  In 
Fig.  168  the  distribution  areas  of  the  different  segments  are  de- 
fined. 

By  an  examination  of  this  figure  it  is  seen  that  the  uterine 
corporeal  pains  are  referred  to  the  lower  abdomen  and  back, 
while  the  cervical  pains  are  referred  to  the  sacral  region,  the 
back  of  the  hip  and  thigh,  and  the  lower  and  back  part  of  the 
foot.  The  pains  due  to  the  ovary  are  reflected  to  the  tenth  dorsal 
visceral  areas,  and  those  from  the  Fallopian  tubes  into  the  elev- 
enth and  twelfth  dorsal  and  first  lumbar  visceral  areas. 

In  this  respect  a  peculiar  characteristic  of  the  genital  pain 
to  be  noted  is  that,  irrespective  of  the  location  of  the  lesion,  the 
pain  is  most  common  on  the  left  side.  ' 

IN'ovak   (117,  p.  480)   states  that  Champneys,  in  a  series  of 


714 


PAIX   IN   THE   FEMALE    GENITALIA 


cases  of  uterine  cancer,  found  the  proportion  between  left-sided 
pain  and  right-sided  pain  to  be  as  six  is  to  one,  and  in  these 
cases  no  greater  tendency  to  involvement  was  present  on  the  left 
than  on  the  right.  Herman,  likewise,  found  that,  in  cases  of 
retrodisplacements  of  the  uterus,  pain  was  three  times  as  fre- 
quent on  the  left  as  on  the  right  side,  without  regard  to  the  fre- 
quency of  the  displacement  on  the  same  side.     Herman  ascribes 


Supply  r  lOtli  D 

the  body  of    j  llth  D 
the  uterus       ^  12th  D 


Fig.  168. — Area  of  Distribution  of  Cord  Segments  Involved  in  Uter- 
ine, Ovarian,  and  Tubal  Diseases. 

The  bodj''  of  the  uterus  is  supphcd  by  the  10th,  11th  and  12th  dorsal  seg- 
ments; the  cervix  by  the  3d  and  4th  lumbar  and  sometimes  by  the  1st 
and  2d  sacral  segments;  the  ovary  by  the  10th,  and  the  Fallopian  tube 
by  the  11th  and  12th.  dorsal  and  the  1st  lumbar  segments. 

the  greater  frequency  of  pain  on  the  left  side  to  the  fact  that 
the  left  side  is  weaker  and  less  resistant  than  the  right.  Accord- 
ing to  Herman  (144,  p.  1,056),  the  greater  frequency  of  pain 
on  the  left  side  has  been  fancifully  explained  as  being  due  to  a 
shortening  of  either  the  left  tube  or  of  the  left  ovarian  ligament. 
It  is  also  explained  by  Clark  (350)  as  being  due  to  tension  of 
the  tightly  drawn  mesentery  over  the  brim  of  the  pelvis.  It  may 
also  in  many  cases  be  partially  explained  from  the  fact  that  on 


GENERAL    CONSIDERATIONS  715 

the  left  side  (in  hysterically  inclined  subjects)  there  is  usually  a 
hysterical  zone  in  the  region  of  the  ovary  (Charcot). 

Sympathetic  pains,  occurring  in  the  occiput  and  breast,  are 
very  frequent  in  disease  of  the  female  genitalia.  The  presence 
of  the  breast  pains  cannot  entirely  be  explained  on  the  hypothesis 
that  the  stimuli  are  carried  through  the  nervous  system,  although 
it  is  probable  that  the  nerve  supply  of  the  breast  has  a  more 
special  connection  with  the  genitalia  than  with  other  organs. 
The  pain  in  the  head,  and  particularly  that  in  the  breast,  seem  to 
be  due  to  an  active  congestion  of  the  meninges  and  of  the  breast 
respectively,  so  that,  in  pelvic  disease,  at  the  time  when  the  pain 
appears  in  the  breast,  the  mammary  gland  swells,  becomes  tender, 
and  the  pain  is  (frequently)  of  the  dull,  aching  variety  that  indi- 
cates capsule  tension.  When  the  pain  is  felt  in  the  head  the 
meninges  are  j^robably  likewise  congested,  and  the  headache  is 
likely  due  to  increased  intraventricular  tension. 

The  cause  of  both  these  congestions  may  be  a  toxin  or  ferment 
either  of  uterine  or  of  ovarian  origin  circulating  in  the  blood. 
This  substance  has  a  selective  action  on  the  meninges  and  on  the 
breast;  the  breast,  because  of  the  related  sexual  functions  of  the 
two ;  and  the  meninges,  because  they  seem  to  be  particularly  sensi- 
tive and  reactive  to  deleterious  circulating  substances  of  any  kind. 

As  yet  a  substance  of  this  nature  has  not  been  separated  from 
the  blood,  nor  has  one  been  produced  from  the  uterine  or  ovarian 
tissue,  though  the  actuality  of  its  existence  seems  to  be  strength- 
ened by  the  fact  that  during  gestation,  with  all  nerves  divided, 
the  mammary  gland  develops.  The  only  way  a  stimulus  could 
be  carried  to  it  is  by  the  blood  (Mott). 

A  peculiarity  of  breast  pains,  that  might  seem  to  show  that 
the  uterus  and  the  breasts  are  correlated  through  the  nervous  sys- 
tem, is  that  breast  pain  is  most  frequent  on  the  side  in  which 
the  diseased  organ  is  located.  If  the  causative  factors  were  car- 
ried through  the  circulation,  why  should  the  breast  on  the  dis- 
eased side  be  more  frequently  involved  ?  As  yet  no  clear  expla- 
nation has  been  offered. 

As  a  conclusion  it  may  be  stated  that  the  female  genitalia  are 


7ie  PAIN   IN    THE   FEMALE   GENITALIA 

capable  of  producing  local,  referred,  reflected,  transferred  an^* 
sympathetic  pains.  The  transferred  pains  are  found  in  some 
cases  of  salpingitis,  in  which  the  pain  is  felt  on  the  side  opposite 
to  the  one  in  which  the  lesion  is  located.  Nearly  all  surgeon? 
have  had  experience  of  such  eases. 

Character  of  Uterine  Pains. — ^While  a  description  of  uterine 
pains  may  entail  some  slight  repetition,  yet,  for  the  sake  of  clear- 
ness, we  shall  again  very  briefly  consider  them.  x\s  has  beeis 
said,  they  may  be  classified  as  constant  and  intermittent.  Th^ 
constant  jDains  are  those  due  to  a  continuously  acting  cause,  sucl? 
as  is  found  in  inflammations  (endometritis,  metritis,  salpingitis- 
and  oophoritis).  Exacerbations  frequently  occur,  producing  in- 
termittent pain,  and  usually  indicate  uterine  contractions.  Con- 
stant pains,  varying  in  intensity  on  change  of  position,  are  found 
where  inflammation  has  been  followed  by  the  formation  of  adhe- 
sions. These  adhesive  formations  are  a  potent  cause  of  pain  pro- 
duction during  the  functional  acts  of  the  parts  involved.  For 
instance,  where  the  uterus  is  attached  by  adhesions  to  the  bladder 
wall,  urination,  owing  to  a  lessened  capacity  of  the  bladder,  tha 
result  of  traction,  etc.,  by  the  adhesions,  becomes  frequent  and 
generally  is  joainful ;  likewise  adhesions  to  the  rectum  are  the 
cause  of  pain  during  defecation,  and  in  some  cases  pain  is  felt 
as  soon  as  the  fecal  matter  begins  to  accumulate  in  and  distend 
the  sigmoid. 

Position  Assumed  hy  the  Patient  Suffering  from  Pelvic  Vis- 
ceral Pain. — Some  women  who  are  afflicted  with  uterine  or  ad- 
nexal  disease  have  no  rest  in  any  position;  standing  or  walking, 
in  motion  or  at  rest,  they  are  always  subject  to  distress.  Their 
pains,  like  an  unwelcome  heritage,  are  ever  with  them.  On  the 
other  hand,  there  are  others  who  have  pain  only  when  they  as- 
sume certain  positions  or  perform  certain  acts.  Very  familiar 
is  the  woman  who  is  always  complaining  of  her  back.  She  has  a 
constant,  steady  aching,  that  is  made  worse  on  bending  and  on 
flexion  of  the  body.  She  will  prove  to  be  one  who  has  a  displaced 
or  retroflexed  uterus.  Women  who  not  only  have  pain  on  standing 
but  on  lying  on  one  side  will  frequently  be  found  to  have  an  acute 


GENERAL    CONSIDERATIONS  717 

inflammatory  state  of  the  adnexa  on  that  side.  Some  women, 
though,  seem  to  have  ease  by  lying  on  the  affected  side.  Bending 
forward  or  backward  is  j^articularly  painful  in  all  pelvic  disease. 
Especially  in  inflammatory  states  of  the  pelvic  peritoneum  are 
frequent  repetitions  of  the  same  act  very  painful. 

On  ascending  stairs  pain  in  the  inguinal  and  lower  abdom- 
inal region,  coming  on  as  the  foot  is  being  removed  from  the 
ground,  generally  indicates  an  involvement  of  the  psoas  muscle 
or  its  sheath  in  the  inflammatory  adnexal  disease.  Pain  on  ele- 
vating the  arm  indicates  an  increase  of  intraabdominal  pressure 
and  disturbed  peritoneal  relations.  This  is  common  in  adhesive 
formations  and  in  pelvic  peritonitis. 

If  the  adhesions  are  to  the  small  bowels  intestinal  peristalsis 
is  painful.  Pain  of  this  sort  comes  on  at  irregular  intervals  and 
is  of  varying  intensity.  It  is  frequently  accompanied  by  a  gur- 
gling which  indicates  the  reduction  of  a  stenosis  and  the  onward 
passage  of  the  bowel  contents,  with  an  almost  immediate  relief 
from  the  pain. 

Relation  of  Pelvic  Visceral  Pain  to  Functional  Acts. — In  all 
acute  and  some  chronic  inflammations  of  the  pelvic  viscera,  and 
in  those  cases  of  adhesive  union  between  different  viscera,  pain 
is  present  on  coitus.  This  pain  may  be  severe  during  the  entire 
act  or  may  be  present  only  at  the  end,  and,  in  either  case,  may 
persist  for  some  time  after  the  act.  When  it  is  present  during 
the  entire  act  it  is  generally  due  to  an  acute  inflammation,  which 
has  progressed  beyond  the  uterus  and  has  involved  the  adnexa. 
This  pain  persists,  as  a  rule,  for  some  time  after  the  act.  In 
chronic  pelvic  inflammation  the  pain  may  often  persist  through- 
out the  next  day.  The  site  of  the  inflammation  modifies  the 
pain  to  a  great  .extent.  Inflammation  high  in  the  body  of  the 
uterus  generally  does  not  cause  as  much  pain  as  if  the  inflamma- 
tion were  low  down  in  the  cervix.  Of  course,  vaginitis  or  cys- 
titis will  also  cause  pain,  and  should  be  considered.  This  pain 
is  present  on  the  entrance  of  the  male  part,  while  the  pain  of 
the  inflammatory  and  adhesive  states  is  present  only  during  the 
act,  and,  in  many  cases  of  mild  inflammatory  states  persists  only 


718  PAIN   IN    THE   FEMALE    GENITALIA 

during  the  time  of  the  active  movements.  When  it  persists  after 
the  cessation  of  these  movements  it  is  a  sign  that  some  damage 
has  been  done  to  the  female  parts.  If  the  patient  has  pus  tubes, 
a  pain  persisting  in  the  tubal  area  after  the  completion  of  the 
sexual  act  maj,  in  some  cases,  indicate  a  leakage  from  the  tube, 
with  a  peritoneal  irritation.  Pain  on  entrance  of  the  male  organ 
into  the  vagina  may  indicate  a  bartholinitis,  fissures,  sometimes 
growths,  or  a  tight  introitus,  either  of  spasmodic  (vaginismus) 
or  organic  origin. 

A  pain,  or  rather  an  aching  and  discomfort,  only  present  at 
the  time  of  and  at  the  completion  of  the  sexual  act  (orgasm)  in- 
dicates an  endometritis. 

Menstruation  acts  as  an  exciting  cause  to  pain  production  in 
many  cases  of  pelvic  disease.  When  the  pain  comes  on  prior  to 
menstruation  it  indicates  an  existing  inflammation,  very  fre- 
quently of  the  tubes.  Frequently,  also,  it  is  the  best  sign  of  a 
cirrhotic  ovary.  Pain  during  the  early  stages  of  the  menstrua- 
tion indicates  (generally)  a  stenosis  of  the  cervix,  while  if  pres- 
ent during  the  entire  time  it  indicates  an  inflammation  of  the 
uterus  or  adnexa.  Pain  existing  prior  to  and  relieved  by  men- 
struation indicates  a  uterine  congestion,  a  very  probable  cause 
of  which  is  fibroid  tumor. 

Relation  of  Pelvic  Visceral  Pain  to  Motion  and  Change  of 
Position  of  the  Patient. — In  diseases  of  the  genitalia  all  vibra- 
tory motion  produces  pain,  which  is  especially  well  marked  dur- 
ing violent  movements,  such  as  occur  during  horseback  riding, 
jumping  and  running.  A  form  of  motion  particularly  productive 
of  pain  is  that  which  occurs  in  sweeping,  and  in  the  lifting  or 
moving  of  heavy  objects. 

This  pain  probably  depends  for  its  production  upon  the  in- 
crease of  the  intraabdominal  pressure,  due  to  contraction  of  the 
muscles  of  the  abdominal  walls.  Certain  functional  acts,  such  as 
vomiting,  also  incite  pain.  The  vomiting  causes  extremely 
marked  variation  in  the  intraabdominal  pressure  and  visceral  re- 
lationships, and  this  probably  leads  to  the  pain  production. 

Certain  ordinary  acts  of  every-day  life  may  also  be  produQ- 


GENERAL    CONSIDERATIONS  719 

tive  of  pain,  for  instance,  a  patient  who  has  a  unilateral  pelvic 
inflammation  finds  it  difiicnlt  to  sit  down  and  cross  the  limb  of 
the  affected  side  over  the  other  limb  in  a  posture  which  I  have 
called  "lacing-the-shoe  position"  (q.  v.).  Pain  during  this  act  is 
due  both  to  the  direct  pressure  of  the  limb  against  the  tender 
abdomen,  and  to  the  stretching  of  the  psoas  and  the  increase  of 
the  intraabdominal  pressure. 

In  all  cases  where  inflammation  is  beginning  to  spread  from 
the  pelvic  viscera  to  the  adjacent  tissue  the  patient  voluntarily 
seeks  quiet,  and,  because  of  the  resultant  pain,  is  not  easily 
aroused  from  her  lethargy. 

Tenderness  due  to  pelvic  lesions  can  be  elicited  either  by  ab- 
dominal or  vaginal  examination.  The  abdominal  examination  is 
divided  into  the  superficial  and  the  deep. 

The  superficial  examination  is  limited  to  defining  the  areas 
of  hyperalgesia.  The  limits  of  these  areas  have  been  given  under 
the  heading.  Reflected  Pain  (q.  v.).  The  value  of  these  diag- 
nostic phenomena  in  pelvic  disease  is  that  they  frequently  offer 
a  "leader"  as  to  where  to  search  for  the  lesion  causing  ill-defined 
abdominal  pain  and  discomfort.  As  no  physician  or  surgeon  relies 
absolutely  ujDon  one  symptom  in  forming  a  diagnosis,  so  the  phe- 
nomenon of  hyperalgesia  should  not  be  taken  as  pathognomonic  of 
any  one  disease,  but  rather  should  be  used  as  an  aid  in  confirming 
or  contradicting  the  conclusions  arrived  at  by  other  means. 

Tenderness  produced  on  deep  palpation  is  more  reliable  and 
helpful  than  that  produced  by  superficial  palpation.  Where  ten- 
derness is  being  sought  for,  the  relationship  of  the  pelvic  viscera 
to  the  anterior  abdominal  wall  should  be  borne  in  mind.  The 
uterus  lies  deep  in  the  abdominal  cavity,  and  the  tubes  likewise 
are  deeply  placed.  They  are  in  intimate  contact  with  the  perito- 
neum. Any  inflammation  of  these  viscera  quickly  spreads  to  the 
surrounding  tissue,  and,  because  of  the  abundant  lymphatic  sup- 
ply, the  area  of  involvement  is  much  greater  than  is  apparent. 
This  is  the  reason  that  the  tenderness  is  much  more  extensive  in 
these  inflammatory  conditions  than  one  would  expect  from  the 
type  of  lesion. 


720 


PAIN   IN    THE   FEMALE   GENITALIA 


._^  / 


/o'* 


A  method  of  eliciting  abdominal  tenderness  in  tubal  disease 
is  to  make  pressure  with  the  hand,  with  a  slowly  progressive, 
downward  motion,  in  the  iliac  fossa,  so  as  to  pinch  the  tube  and 
ovary  between  the  hand  and  the  pelvic  wall.  As  soon  as  the  ovary 
and  the  tube  are  caught  the  patient  makes  an  outcry,  and  the 

lower  segTiient  of  the  rectus  muscle 
becomes  rigid.  This  sign  cannot 
always  be  elicited,  for  in  some  cases 
rigidity  of  the  rectus  is  so  great 
that  it  is  impossible  to  press  the 
hand  into  the  pelvic  fossa.  A 
method  of  making  use  of  the  ob- 
servations of  Mackenzie,  that  "the 
muscular  tissues"  and  of  Lennan- 
der  that  "the  subperitoneal  tissues" 
are  tender  in  visceral  disease,  is  to 
place  the  hand  palm  downward  on 
the  upper  part  of  the  thigh,  and 
tlien,  with  the  fingers  slightly 
flexed  and  depressed  into  the  flesh, 
to  draw  the  hand  upward  over  the 
abdomen.  As  soon  as  the  fingers 
pass  above  Poupart's  ligament,  and 
a  drag  is  made  upon  the  abdominal 
muscles  and  peritoneal  tissues,  the 
patient  complains  of  pain.     These 

tubal  tenderness;  u,   uterine      signs  are  only  confirmative  of  other 

tenderness;  u',  accessory  uter-        _      ^  i  j.   4.     i 

,      ,     '     '  ''  svmptoms  and  are  not  to  be  con- 

ine  tenderness.  "     ^ 

sidered  of  pathognomonic  value. 
In  this  connection,  the  areas  of  tenderness,  as  found  by  Donald 
and  Lickley  (138,  p.  434)  in  pelvic  visceral  disease,  are  of 
interest.  They  found  that,  by  pinching  the  skin  between  the 
fingers,  or  by  making  slight  pressure  upon  it,  certain  areas  or 
points  were  more  sensitive  than  others.  Each  of  these  areas 
seems  to  have  a  certain  definite  relationship  to  a  visceral  organ. 
The  area  connected  with  the  ovary  is  slightly  below  the  umbilicus, 


Fig.  169. — Points  of  Tender- 
ness AS  Elicited  by  Donald 
AND  Lickley  (138)  in  Ova- 
rian, Tubal,  and  Uterine 
Diseases. 

ov,  ovarian  tenderness;  ov',  ac- 
cessory ovarian  tenderness;  T, 


GENERAL    CONSIDERATIONS  721 

and  about  two  inelies  to  one  side  of  the  median  line.  It  lies  on 
the  intersection  of  a  line  joining  the  umbilicus  to  the  antei'ior 
superior  spine,  with  a  line  lying  on  the  outer  border  of  the  rectus. 
At  this  point  the  eleventh  dorsal  nerve  pierces  the  sheath  of  the 
rectus  and  becomes  superficial,  so  that,  because  of  its  exposed 
position,  pressure  may  easily  be  exerted  upon  it.  There  is  also 
found  an  associated  area  of  tenderness  on  the  lateral  wall,  at  the 
point  where  the  lateral  cutaneous  branch  of  the  eleventh  nerve 
becomes  subcutaneous.  The  area  associated  with  tubal  disease  is 
found  at  the  intersection  of  the  horizontal  line  joining  the  two 
anterior  sjiincs  with  the  outer  margin  of  the  rectus  sheath.  It 
corresponds  to  the  point  of  emergence  of  the  twelfth  dorsal  nerve. 

The  uterine  area  is  located  over  the  inguinal  ring.^  At  the 
internal  ring  the  ilioinguinal  nerve  enters  the  canal  and  becomes 
superficial.  Other  areas  of  tenderness  associated  with  the  uterus 
are:  (1)  immediately  below  Poupart's  ligament,  where  pressure 
on  the  anterior  crural  is  painful;  (2)  an  area  extending  from 
the  outer  margin  of  the  erector  spina3  muscle  to  the  gluteal  re- 
gion, following  the  posterior  divisions  of  the  first  three  lumbar 
•nerves  (this  area  generally  is  associated  with  disease  of  the 
body  of  the  uterus)  ;  (3)  in  some  cases  also  there  is  a  tender 
area  over  the  sacrum  from  the  second  sacral  vertebra  to  the  coc- 
cyx. This  area  extends  laterally,  and  in  extent  corresponds  to 
the  posterior  primary  divisions  of  the  mid-sacral  nerves,  and  may 
be  j^resent  in  diseases  of  the  cervix  uteri. 

The  most  responsive  of  all  these  areas  to  disease  of  their  asso- 

1  Regarding  the  cause  of  tenderness  at  the  internal  inguinal  ring,  two 
theories  are  given:  (1)  the  mechanical,  and  (2)  the  reflex  neurological.  In 
regard  to  the  former,  the  points  apparently  in  its  favor  are  the  dragging  nature 
of  the  pain,  and  its  location  at  a  point  where  the  broad  ligaments  are  inserted. 
This  would  be  of  considerable  value  if,  in  all  cases  in  which  the  pain  is  present, 
a  dragging  on  this  section  of  the  abdominal  wall  were  made  by  the  broad  liga- 
ments, or  if,  in  all  cases  in  which  dragging  is  found,  pain  were  present.  Many 
examples  of  each  of  these  states  without  pain  production  at  this  point  can  be 
foi:nd,  and  their  profusion  rather  negatives  the  value  of  this  deduction.  On 
the  other  hand,  it  has  been  found  that  electrolysis  of  the  uterus  will  produce 
pain  in  this  same  area,  without  any  general  disturbance  of  relationship  of  the 
other  organs.  This  would  indicate  that  if,  in  all  cases,  the  pain  is  not  pro- 
duced reflcxly,  at  least  in  every  ease  it  is  capable  of  being  so  produced. 


722  PAIN   IN    THE   FEMALE    GENITALIA 

ciated  organs  is  the  ovarian,  while  the  nterine  area  is  the  least 
responsive. 

A  bimanual  vaginal  examination  should  be  made  on  every 
patient  who  complains  of  pelvic  pain.  Often  the  tube  can  be  felt 
through  the  abdominal  wall  to  be  enlarged  and  tender ;  even  tender- 
ness of  the  ovary  can  sometimes  be  elicited.  When  pressure 
is  made  upon  either  of  these,  reflected  or  referred  pain  will 
be  felt  in  the  cutaneous  areas  associated  with  them.  During  the 
vaginal  examination  the  fingers  in  the  vagina  should  push  the 
cervix  from  side  to  side.  If  the  adnexa  of  one  side  are  diseased, 
pain  is  complained  of  in  that  side.  In  case  of  adhesions  pain  is 
•produced  when  the  position  of  the  uterus  is  such  that  the  adhe- 
sions are  put  on  the  stretch.  Acute  inflammatory  conditions  are 
painful  either  on  pressure  or  on  traction.  The  pain  is  felt  on 
the  side  manipulated,  and  is  produced  either  by  pushing  or 
by  rotating  the  uterus  toward  the  opposite  side  or  by  pressing  it 
against  the  diseased  tissues.  Rotation  of  the  uterus  may  be  ac- 
complished by  using  the  cervix  as  a  fulcrum  to  make  pressure  in 
the  direction  opposite  to  that  in  which  it  is  desired  to  have  the 
uterus  turn.  Pain  on  drawing  the  cervix  forward  and  downward 
may  be  due  to  a  short,  sensitive,  uterosacral  ligament  (I^ovak), 
inflammation  of  the  parametrium,  or  recent  uterine  adhesions. 
According  to  Garrigues  (163)  pain  is  produced  at  the  side  of 
the  second  sacral  vertebra  by  pressure  on  the  corresponding  utero- 
sacral ligament.  * 

Diagnosis  of  Pelvic  Diseases. — Of  value  in  the  diagnosis  of 
pelvic  diseases  are: 

(1)  The  history  of  the  case,  which  should  always  be  carefully 
reviewed.  The  manner  of  the  onset  of  the  present  symptoms 
and  their  duration  should  be  defined.  It  should  also  be  deter- 
mined if  they  came  on  after  a  suspicious  intercourse.  Yet  the 
absence  of  such  a  history  should  not  be  of  too  great  influence  in 
the  forming  of  a  diagnosis.  For  in  many  cases  of  pelvic  disease, 
gonorrheal  in  origin,  the  patient  has  innocently  acquired  the 
coccus  from  an  impure  husband,  and  does  not  know  of  her  affec- 
tion, so  that  a  negative  history  is  but  of  slight  value  in  forming 


GENERAL    CONSIDERATIONS  723 

an  opinion.  In  others  puerperal  sepsis  is  the  cause  of  the  trouble. 
What  proportion  of  pelvic  lesions  come  from  other  causes  than 
the  above  is  rather  hard  to  decide,  but  the  common  opinion  is 
that  it  is  very  small.  The  non-specific  lesions  causing  pain  are 
tumor,  tuberculosis,  etc. 

(2)  After  a  history  of  the  onset  a  good  description  should  be 
obtained  of  (a)  the  character  of  the  discharge,  and  (b)  the  type 
and  character  of  the  menstrual  flow.  In  specific  infection  the 
vaginal  discharge  generally  is  thick  and  creamy,  and  if  the  disease 
has  to  any  extent  invaded  the  uterus  is  usually  of  a  foul  odor. 
A  mixture  of  blood  may  indicate  (unless  it  occurs  at  the  men- 
strual time)  an  endometritis  or  extrauterine  pregnancy.  A  slight 
whitish  discharge  before  or  after  the  menstrual  period  is  of  no 
diagnostic  value,  as  it  is  a  common  occurrence  in  many  normal 
women.  The  vaginal  discharge  should  always  be  examined  mi- 
croscopically in  order,  definitely,  if  possible,  to  identify  the  caus- 
ative germ. 

Because  it  is  so  common,  and  occurs  in  so  many  ways,  it  is 
very  difficult  to  derive  any  useful  information  from  menstrual 
disturbance ;  but  change  in  its  character  is  of  great  significance  in 
extrauterine  pregnancy,  cancer,  fibroid,  and  pelvic  inflammation. 

As  predisposing  factors  to  the  production  of  pain  in  tubo- 
ovario-uterine  disorders  may  be  mentioned  anemia,  severe  or  pro- 
longed illness,  depressing  mental  influences  causing  a  lessened 
psychic  resistance,  and  starvation.  Before  passing  on  to  a  more 
special  consideration  of  the  pain-phenomena  in  the  special  or- 
gans composing  the  pelvic  viscera,  it  is  well  to  consider  in  a 
nervous,  high-strung  woman  the  possibility  of  the  presence  of 
hysteria.  In  this  condition  many  other  criteria  and  indications 
of  involvement  are  present — for  instance,  the  eye  phenomena  and 
the  areas  of  anesthesia  and  hyperesthesia  present  in  other  parts 
of  the  body — and  even  though  a  severe  pain  may  be  complained 
of  over  the  region  of  the  ovary  (the  so-called  ovarian  neuralgia), 
it  is  not  associated  with  such  severe  local  abdominal  rigidity  as 
are  organic  lesions  of  the  ovaries,  tubes,  or  uterus. 

After  this  brief  survey  of  the  principal  causes  for  pelvic  pain 


724  PAIN   IN    THE   FEMALE    GENITALIA 

and  the  areas  in  which  it  is  found,  it  is  well,  before  a  more  de- 
tailed description  is  undertaken,  to  offer  as  a  caution  to  those 
who  consider  only  the  symptoms  and  not  the  patient,  Novak's 
warning.  He  says :  "The  gynecologist  must  learn  to  look  on 
pain  as  the  resultant  of  two  factors,  the  lesion  and  the  patient; 
and  in  order  to  arrive  at  an  intelligent  appreciation  of  the  true 
significance  of  pelvic  j^ain  he  must  study  both  these  factors  with 
equal  fidelity." 

UTERINE  PAIN 

As  a  slight  review  of  what  has  proceeded,  let  it  be  recalled  that 
the  uterus  is  supplied  by  two  sets  of  nerves,  the  cerebrospinal  and 
the  sympathetic.  The  cerel)rospinal  nerves  are  derived  principally 
from  the  second,  third,  and  fourth  sacral  nerves,  and  supply  the 
lower  segment  of  the  uterus.  It  is  owing  to  the  stretching  of 
these  nerves  in  labor,  and  pressure  upon  them  by  cicatrices  and 
the  like,  that  pain  is  felt.  Above  the  cervix  the  muscular  tissue 
is  su2:)plied  by  sympathetic  nerves  from  the  hypogastric  plexus. 
The  nerves  forming  this  plexus  are  derived  principally  from  the 
tenth,  eleventh,  twelfth  dorsal,  and  first  lumbar,  the  third  and 
fourth  sacral,  and,  at  times,  the  first  and  second  visceral  sacral 
segments. 

There  seems  to  be  some  relationshij)  between  the  uterine  and 
the  nasal  mucosa,  for,  according  to  Chrobak,  there  is  "apparently 
a  connection  between  the  two  organs,  and  pains  of  a  genital  type 
can  be  relieved  or  stopped  by  the  application  of  coca  in  (5  to  10 
per  cent.,  a  few  drops  on  cotton)  to  the  sej)tum  or  the  lower  tur- 
binate bone."  He  found  that  "labor  was  made  less  painful,  and 
in  one  instance  even  painless."  However,  this  might  have  been 
the  result  of  suggestion.  Yet  it  is  a  fact  that  smell  and  the 
genesic  sensibility  are  connected  in  a  variety  of  ways. 

Character  of  Uterine  Pains. — Uterine  pain  has  certain  charac- 
teristics, namely,  it  is  of  irregiilar  intensity;  at  times  it  may  bo 
constant  and  remain  so  for  some  time ;  or  the  constancy  may  be 
interrupted  by  a  violent  paroxysm,  and  the  pain  may  then  as- 
sume the  type  of  a  colic.     In  fact,  it  is  this  colicky,  cramjD-like 


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726  PAIN   IN   THE   FEMALE    GENITALIA 

manifestation  which  makes  uterine  pain  so  characteristic.  An- 
other characteristic  is  its  intensity,  for  the  uterine  pain  is  one 
of  the  most  intense  that  the  human  organism  endures.  Espe- 
cially is  this  true  of  labor  pains.  In  most  cases  uterine  disorder 
causes  a  pain  in  the  back;  in  fact,  a  dragging  pain  in  the  back 
is  said  to  be  characteristic  of  uterine  disorder.  The  pains  due 
to  disease  of  the  uterus  will  not  at  this  time  be  minutely  con- 
sidered. Later  the  different  pains  and  the  factors  producing 
each  will  be  discussed. 

The  disorders  of  the  uterus  causing  pain  are:  (1)  neuralgia, 
(2)  displacement,  (3)  functional  acts  (as  menstruation,  preg- 
nancy, and  childbirth),  (4)  inflammation  (as  endometritis,  me- 
tritis, peri-  and  parametritis),  and   (5)  new  growths. 

Neuralgia. — JSTeuralgia  of  the  uterus  is  often  (as  was  said  when 
the  term  was  used  in  speaking  of  pains  in  other  organs)  but  a 
cloak  for  ignorance.  That  neuralgia  may  occur  in  the  uterus,  the 
same  as  in  other  organs,  cannot  be  doubted ;  but,  even  so,  the  term 
is  generally  used  by  the  attending  physician  to  hide  his  lack  of 
diagnostic  skill.  A  diag^losis  of  neuralgia  should  be  made  only 
after  a  negative  search  for  lesions  of  sufficient  gravity  to  cause 
the  pain.  I^^euralgia  is  frequently  a  term  wrongly  used  in  speak- 
ing of  the  pain  due  to  endometritis,  etc. 

Displacement  of  the  Uterus. — Displacement  of  the  uterus,  of 
itself,  does  not  produce  anj^  severe  pain,  though  it  is  frequently 
the  cause  of  the  aching  in  the  back,  so  common  in  this  disorder. 
This  aching  is  due  to  two  factors:  (a)  the  drag  upon  the  liga- 
ments attaching  the  uterus  to  the  pelvis,  and  (b)  the  congestion 
of  the  uterus  from  partial  obstruction  to  the  return  blood  flow 
in  the  broad  ligaments.  The  displacement,  of  itself,  produces  a 
direct  pain,  localized  in  the  tissues  deep  in  the  back.  Unless  con- 
gestion is  excessive  the  pain,  the  result  of  displacement,  disappears 
on  replacing  the  uterus  in  the  normal  position.  However,  if  the 
congestion  is  excessive  the  pain  does  not  disappear  so  readily  on 
the  correction  of  the  mechanical  defect,  because  it  takes  time  to 
eradicate  the  changes  which  have  taken  place  in  the  structure  of 
the  uterus  following  a  long-continued  congestion,  and  which  have 


UTERINE    PAIN  727 

been  acting  as  causative  factors  of  pain  production.  When  con- 
gestion and  structural  changes  occur,  sensory  disturbances  in 
Head's  zone  also  apj^ear,  and  persist  until  recovery  has  taken 
place.  In  some  cases,  where  the  uterosacral  ligaments  are  par- 
ticularly sensitive,  a  slight  drag  or  pull  upon  them  by  an  en- 
larged uterus,  or  by  the  examiner,  through  traction  made  on  the 
cervix,  will  produce  a  very  severe  pain. 

Character  of  the  Displacement  Pain. — Displacement  produces 
more  of  an  aching  in  the  back  than  an  actual  pain.  In  some 
cases,  where  the  displacement  is  excessive,  as  in  complete  pro- 
lapsus, traction  may  be  made  upon  some  of  the  nerves  arising 
from  the  sacral  plexus.  When  this  happens  pain  occurs  in  the 
distribution  area  of  these  nerves  (sacral  plexus).  In  fact,  under 
such  circumstances,  any  of  the  nerves  passing  through  the  pelvis 
may  be  interfered  with  and  pain  be  produced.  The  pain  of  dis- 
placement is  made  worse  on  walking,  especially  should  the  dis- 
placement have  been  transformed  into  a  prolapsus.  The  pain  in 
retrodisplacement  is  eased  only  by  lying  on  the  abdomen  and  is 
increased  by  lying  on  the  back,  while  in  prolapsus,  ease  comes  on 
lying  down  in  any  position.  On  the  other  hand,  all  changes  of 
position  are  painful  if  adhesions  bind  the  uterus  to  adjacent  struc- 
tures. Then  the  pain,  instead  of  being  entirely  of  uterine  origin, 
is  modified  by  that  due  to  disturbances  in  other  closely  related 
organs.  Antero-displacement  is  not  as  painful  as  retrodisplace- 
ment, possibly  because  the  anterior  displacement  occurs  in 
younger  people  in  whom  the  pelvic  structures  have  not  been  in- 
jured by  childbirth,  and  in  whom  other  associated  changes  are 
not  so  likely  to  be  present.  In  retrodisplacement  defecation  is 
sometimes  painful,  while  in  displacements  of  the  anterior  type 
there  are  often  both  complaint  of  pain  during  defecation  and  a 
frequency  of  urination.  In  anterior  displacements  there  may 
also  be  a  sense  of  pressure  or  of  aching  behind  the  symphysis 
pubis. 

Displacements  are  among  the  common  causes  of  dysmenor- 
rhea (Herman,  Kelly).  In  displacement  there  often  is  an  angu- 
lation of  the  cervix,  so  that,   during  the  menstrual  period,  the 


728  PAIN   IN    THE   FEMALE    GENITALIA 

blood  and  membranes  are  not  so  easily  discharged,  because  of  the 
narrowing  of  the  canal,  due  to  the  angulation.  As  a  conse- 
quence, the  menstrual  discharge  from  the  uterus  is  hindered,  and 
uterine  colic  results. 

Functional  Disorders  of  the  Uterus. — The  principal  functions 
of  the  uterus  are  menstruation,  pregnancy,  and  childbirth.  The 
first  two  should  be  j)ainless;  but  unfortunately,  as  a  price  of  our 
higher  civilization,  the  woman  finds  that  frequently,  instead  of 
these  being  periods  of  well  being  and  content,  they  are,  because 
of  the  frightful  pain  and  distress  which  she  suffers,  periods  of 
dread  and  dismay. 

MENSTEUATIO^^. — Amoug  savages,  menstruation  is  generally 
without  pain,  and  even  among  those  of  higher  civilization  it  is  fre- 
quent to  find  the  menses  coming  on  without  distress.  Yet,  as  civ- 
ilization advances,  and  our  women  mount  the  ladder  of  indolence 
and  ease,  pain  and  distress  gradually  become  more  and  more 
pronounced,  until,  at  the  summit,  in  our  latter-day  civilization, 
woman  is  incapacitated  for  a  greater  part  of  her  time  by  condi- 
tions which  ordinarily  should  cause  but  slight,  if  any,  incon- 
venience. 

Painful  menstruation  is  termed  dysmenorrhea.  Holden  ana- 
lyzed the  histories  of  one  thousand  consecutive  cases  of  abnormal 
pelvic  conditions  with  reference  to  the  occurrence  of  this  symp- 
tom. As  the  result  of  his  observations  he  presents  the  following 
conclusions : 

"Dysmenorrhea  is  present  in  47  per  cent,  of  all  gynecologic 
hospital  patients.  In  about  23  per  cent,  of  the  entire  number  it 
seems  to  be  definitely  caused  by  certain  abnormal  conditions  of  the 
pelvic  organs.  In  22  jier  cent,  of  the  entire  number  it  is  present 
in  conjunction  with  such  conditions,  but  is  apparently  not  caused 
by  them.  The  pathologic  conditions  which  are  most  frequently 
seen  as  the  causes  of  dysmenorrhea  are:  (1)  retrodisplacements  of 
the  uterus,  (2)  pelvic  inflammatory  disease,  and  (3)  myomata. 
These  three  conditions  account  for  nearly  90  per  cent,  of  all  the 
dysmenorrhea  which  is  caused  by  pathologic  conditions  of  the 
pelvic  organs.     Retrodisplacement  accounts  for  41  per  cent.,  pel- 


UTERINE   PAIN  729 

vie  inflammatory  disease  for  37  per  cent.,  and  myomata  for  11 
per  cent.  Of  nulliparons  patients  with  retrodisplacements  causing 
symptoms,  86  per  cent,  have  dysmenorrhea.  The  frequency  of  this 
association  leads  to  the  conchision  that  the  abnormal  position  causes 
the  dysmenorrhea.  In  retrodisplacements  occurring  after  child- 
birth it  is  much  less  common;  25  per  cent,  of  multiparse  with 
retrodisplacements  have  dysmenorrhea,  which  is  apparently  caused 
by  the  malposition.  Of  all  the  patients  with  pelvic  inflammatory 
disease,  31  per  cent,  have  dysmenorrhea,  which  is  apparently 
caused  by  the  condition.  Of  all  the  cases  of  myoma,  20  per  cent. 
have  dysmenorrhea  apparently  caused  by  the  tumor." 

During  the  normal  menstruation  the  uterine  muscles  undergo 
a  slight  contraction,  but  not  of  sufficient  strength  to  be  felt  as  such 
(Winter,  Menge).  The  factors  that  would  cause  the  normal  con- 
traction to  become  abnormal,  either  in  regard  to  the  time  or  the 
strength  of  the  contractions,  are :  some  hindrance  to  the  expulsion 
of  the  menstrual  blood  (as  a  contracted  os  uteri),  an  inflammatory 
thickening  of  the  endometrium,^  or  a  faulty  position  of  the 
uterus  in  which  it  is  flexed  and  the  cen-ical  canal  is  angulated. 
Stenosis  of  the  external  os  is  not  as  frequent  a  cause  of  pain  pro- 
duction as  is  stenosis  of  the  internal  os.  Winter  says  that  he  has 
occasionally  seen  collections  of  blood  behind  the  external  os  sufli- 
cient  to  cause  ballooning  of  the  cervix  without  causing  the  least 
pain. 

Dysmenorrhea,  when  due  to  cervical  stenosis  or  angulation 
from  whatever  cause,  is  generally  relieved  by  pregnancy.  If  the 
dysmenorrhea  be  entirely  mechanical,  or  be  due  to  some  struc- 
tural defect  (either  a  narrowing  or  contraction  of  the  cervix,  or 
an  angulation  of  the  same  from  a  faulty  position  of  the  uterus), 
it  is  found  that  the  menstrual  pain  dates  from  the  period  of  the 
first  menstruation  or  from  the  time  of  some  operative  interfer- 
ence. It  is  very  characteristic,  in  that  it  begins  only  a  very  short 
time,  a  few  hours,  before  the  blood  commences  to  flow,  and  con- 

1  Theilhaber  claims  that  25  per  cent,  of  all  cases  of  dysmenorrhea  are 
caused  by  a  stenosis  of  the  een-ix,  either  congenital  or  acquired.  Theilhaber 
also  claims  that  in  hysteria  a  contraction  of  the  circular  muscular  fibers  of 
the   cervix   may   occur,  causing  a   stenosis  and   consequent   pain. 


730  PAIN   IN    THE   FEMALE    GENITALIA 

tinucs  as  long  as  the  blood  flow  is  active,  and  then  ceases  as 
abruptly  as  it  came  on.  All  other  forms  of  dysmenorrhea  gener- 
ally start  a  day  or  two  previous  to  the  flow,  and  are  the  result 
of  the  pelvic  congestion  incident  to  the  flow.  If  anteflexion  is 
suspected  as  the  cause  of  the  dysmenorrhea,  to  make  the  diag- 
nosis certain  it  is  necessary  that  there  should  be  present  a  freely 
movable,  normally  developed  uterus,  in  permanent,  rigid  ante- 
flexion, in  a  person  Avho  is  neither  nervous  nor  hysterical 
(Winter) . 

In  some  cases  congestion  of  the  endometrium,  incidental  to  the 
menstrual  flow,  may  block  up  the  cervical  passage,  and  the  expul- 
sion of  the  uterine  contents  is  difficult. 

Spasmodic  contraction  of  the  cervix  is  a  frequent  cause  of 
uterine  pain.  This  spasmodic  contraction,  according  to  Herman, 
is  due  to  the  fact  that  the  uterine  center  in  the  cord,  or  in  the 
sympathetic  system  which  regulates  the  movements  of  the  genital 
canal,  is  imperfectly  developed.  The  vagina,  uterus,  and  Fallopian 
tubes  are  muscular  organs  like  the  intestine.  During  the  sexual 
orgasm  there  is  coordinated  muscular  action  of  these  organs,  the 
object  being  to  help  the  ovum  from  the  tube  and  the  spermatozoa 
from  the  vagina  into  the  uterus.  In  a  normal,  painless  men- 
struation there  is  also  a  coordinated  action,  the  body  of  the  uterus 
contracting  and  the  cervix  dilating,  so  that  the  menstrual  flow  is 
expelled  without  pain  or  difficulty.  In  this  neurotic  variety  of 
dysmenorrhea  the  natural  dilatation,  because  of  changes  in  the 
cord  or  sympathetic  ganglia  located  in  the  cervix,  is  absent ;  and 
as  a  consequence  the  .contractions  of  the  uterine  body  are  mor- 
bidly violent  and  painful.  The  only  physical  sign  observed  in 
these  cases  of  dysmenorrhea  is  difficulty  in  dilating  the  cervix. 

Another  cause  of  dysmenorrhea  is  hindrance  to  the  separation 
of  the  decidual  membrane.  Owing  to  degeneration  or  disease  the 
endometrium  may  be  difficult  to  separate  entirely.  Parts  of  it, 
not  being  entirely  free,  lie  loose  in  the  uterine  cavity,  and  may 
cause  repeated  and  violent  contractions  of  the  uterus.  Endome- 
tritis is  one  of  the  most  common  causes  of  this  condition.  Mem- 
hranous  dysmenorrhea  gives  rise  to  large,  free  masses  of  mem- 


UTERINE   PAIN  73JL 

branous  tissue  in  the  uterine  cavitv,  and  it  is  the  effort  of  the 
uterus  to  expel  them  which  probably  causes  pain.^ 

Endometritis  dolorosa  is  the  name  given  to  an  endometritis  in 
which  severe  pain  is  present ;  but  here  again  the  pain  is  due  to  a 
compression  of  the  uterine  nerves,  for  as  soon  as  a  dilatation  of  the 
cervix  is  performed  the  pain  vanishes  (Sneguereff). 

Maldevelopment  of  the  uterus  acts  as  a  cause  of  pain  during 
menstruation.  In  these  cases  the  uterine  cavity  is  so  small  that 
during  menstrual  congestion  the  two  walls  become  so  swollen 
that  they  completely  block  up  the  opening  and  the  blood  and  men- 
strual debris  cannot  be  discharged.  Winter  accounts  for  this 
form  of  dysmenorrhea  as  the  result  of  reflex  contractions  of  the 
uterine  musculature,  the  reflex  in  turn  being  the  result  of  in- 
creased pressure  in  the  uterine  vessels;  the  increased  pressure 
being  due  to  the  facts,  that  the  vessels  are  too  small  to  allow  for 
the  accumulation  of  the  blood,  and  that  the  cavity  of  the  uterus  is 
too  narrow  to  permit  the  necessary  degree  of  swelling  of  the 
mucous  membrane. 

Hyperesthesia  of  the  muscles  (uterine)  and  of  the  uterine 
mucous  membrane  may  also  be  present.  These  may  cause  con- 
traction of  the  uterus  during  menstruation,  when  otherwise  the 
menses  would  have  been  normal.  Such  is  the  case  in  those  indi- 
viduals of  a  neurasthenic  nature,  in  whom  we  so  often  find  a 
marked  dysmenorrhea.  Very  frequently  this  variety  of  dys- 
menorrhea is  also  found  in  those  of  reduced  vitality. 

It  may  be  that  in  some  of  these  jDatients  the  receptive  state 
of  the  nervcftis  system  is  also  in  a  peculiar  irritative  condition  in 
which  it  responds  to  lighter  stimuli  than  ordinarily  would  af- 
fect it. 

In  cases  of  this  character  the  pain  is  not  relieved  on  lying 
down,  as  it  is  when  the  dysmenorrhea  is  of  congestive  origin.  It 
generally  begins  with  the  flow  and  is  of  very  short  duration.     The 

1  Painful  areas,  present  in  one  case,  were  (Sneguereff)  the  tuberosity  pubis 
on  each  side,  the  inner  surface  of  the  thighs,  the  renal  plexus  on  both  sides,  the 
solar  plexus,  the  rectum  ( ?)  and  the  anterior  superior  spine.  Perineal  areas 
were  the  emerging  point  (1)  of  the  ilioinguinal,  (2)  of  the  sup.  int.  cutan., 
and   (3)  of  the  pudic. 


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A  history  of  tubercular  in- 
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may  be  involved,  though  in 
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History  of  present  preg- 
nancy.     History    of    an 
endometritis  present  be- 
,fore  pregnancy  began. 

Occurs  in  the  early  course 
of    pregnancy    and    per- 
sists   for    three    or   four 
months. 

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Symptoms  generally  dis- 
appear in  the  latter  half 
of  pregnancy. 

Resembles     labor     pain. 
Abortion  or  miscarriage 
sometimes  occurs. 

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Membranous     shreds,      or 
even   casts   of   the  uterus; 
are  thrown  off  during  the 
last  stage  of  the  menstrual 
discharge. 

3 
o 
m 

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Very    severe,    being    espe- 
cially marked  at  the  end  of 
the    menstrual    period,    at 
the  time  of  the  separation 
of  the  membranes. 

Neurotic 
Dysmenohuhea 

The  pain  may  date  from  the 
first  menstruation  or  it  may 
come  on  after  years  of  pain- 
less menses.     After  it  once 
commences  it  is  seldom  re- 
lieved except  by  operative 
means  or  by  pregnancy. 

Generally      sudden.     May 
follow  after  years  of  normal 
periods. 

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Occurs  generally  at  the  time 
of  the  menses,  and  is  most 
severe.    It  also  may  occur 
at  intermediate  periods. 

DQ 

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o 

03 

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a 

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733 


734  PAIN   IN    THE   FEMALE    GENITALIA 

individual  spasm  lasts  about  one  minute  and  recurs  with  about 
the  frequency  of  labor  pains.  This  type  often  arises  after  years 
of  painless  menstruation. 

Polypoid  growths  inside  the  uterus  may,  by  hanging  down, 
obstruct  the  cervix,  and  thus,  by  a  ball-valve  action,  be  a  cause 
of  pain. 

Ovarian  dysmenorrhea  is  a  term  used  to  define  the  pain  pro- 
duced in  the  ovary  from  the  congestion  incidental  to  menstrua- 
tion. It  occurs  before  the  flow  commences  and  ceases  as  soon  as 
it  becomes  profuse. 

Possibly  a  fissured  state  of  endometrium  at  the  internal  os 
may  also  excite  such  a  spasm  of  the  uterine  musculature  as  is 
produced  in  the  sphincter  in  anal  fissure.  A  spasm  of  this  type 
is  increased  by  congestion  of  the  tissues.  It  is  given  as  a  cause 
of  pain  by  Keating  and  Coe. 

Winter,  after  a  careful  review  of  the  subject,  gives  the  fol- 
lowing very  clear  conclusions  in  regard  to  menstrual  pain,  namely, 
that  it  is  necessary,  in  order  that  the  natural  process  may  run  a 
painless  course,  that  "nothing  interfere  with  maturation  and  rup- 
ture of  the  follicles ;  that  the  congestion  in  the  uterine  wall  does 
not  meet  with  resistance  from  infiltration  of  the  tissues ;  that  the 
mucosa  be  capable  of  swelling  and  of  taking  up  the  extravasated 
blood ;  that  the  size  of  the  uterine  cavity  be  sufficient  to  accommo- 
date the  swollen  mucous  membrane;  that  the  menstrual  blood 
escape  readily  from  the  cervix,  and  that  the  congestion  of  the 
tubes  and  of  the  peritoneum  take  place  in  normal  tissues.  In  addi- 
tion the  nervous  system  must  joossess  a  normal  degree  of  irritabil- 
ity and  the  psychic  function  must  be  normal ;  othierwise  the  slight 
alterations  which  take  place  in  the  nervous  system  during  normal 
menstruation  may  be  abnormally  exaggerated"  (Winter,  Clark's 
translation) . 

Referred  hyperalgesia  in  the  uterine  segments  is  very  com- 
mon in  all  these  conditions  which  produce  uterine  pain.  Pain  in 
the  breasts  is  also  a  frequent  accompaniment  of  menstruation. 
It  generally  precedes  the  menstrual  discharge  by  a  few  days.  Be- 
cause of  this  breast  pain,  breathing  may  be  painful. 


UTERINE   PAIN  735 

In  resume,  it  may  be  stated  that  menstrual  pain  may  occur 
before,  during,  or  after  menstruation.  When  it  occurs  (1)  be- 
fore menstruation,  it  is  due  to  hindrance  to  the  discharge  of 
blood  from  the  uterus  because  of  (a)  narrowing  of  the  lumen  of 
the  cervix,  the  result  of  a  stenosis  which  has  taken  place  from  a 
chronic  inflammation  of  the  endometrium,  or  from  an  angulation 
of  the  cervix  from  a  flexion  of  the  uterine  body  on  the  neck ; 
(b)  blocking  of  the  lumen  of  the  cervix  by  a  blood  clot  or  by  a 
piece  of  endometrium ;  (c)  obstruction  to  the  menstrual  discharge 
by  a  foreign  body  (as  tumor)  ;  and  (d)  chronic  inflammation  of 
the  ovary,  which  has  caused  a  thickening  of  the  tunica  albuginea, 
so  that  the  Graafian  follicle,  because  of  the  thickness  and  tough- 
ness of  this  layer,  has  great  difficulty  in  penetrating  to  the  sur- 
face ;  congestion  results,  and  this  stretches  the  peritoneal  coat  and 
causes  pain;  (2)  during  menstruation,  it  is  generally  due  to 
chronic  endometritis;  and  (3)  after  menstruation,  it  is  due,  as 
a  rule,  to  inflammation  of  the  adnexa. 

Intermenstrual  pain  is  the  name  given  to  a  pain  which 
generally  comes  on  about  the  middle  of  the  mid-menstrual  period. 
It  usually  lasts  for  two  to  four  days,  though  it  may  persist  till 
the  next  menstruation.  Several  theories  have  been  advanced  as 
to  its  causation.    Among  the  most  reasonable  are : 

(1)  That  it  is  due  to  the  retardation  of  the  outward  passage 
of  the  Graafian  follicle  toward  the  periphery,  by  some  change  in 
the  ovarian  stroma;  the  resultant  congestion  and  tension  pro- 
ducing pain. 

(2)  That  in  cases  of  ovarian  adhesions  the  pain  is  due  to  the 
traction  made  on  these  adhesions  by  recession  of  the  ovary  after 
each  menstrual  period.  This  recession  necessarily  reaches  its 
climax  about  the  middle  of  the  intermenstrual  period  (Reed). 

(3)  Circulatory  changes  in  the  ovary,  causing  ovarian  conges- 
tion, may  also  produce  intermenstrual  pain  (Sheill). 

The  pain  resulting  from  these  factors  may  vary  from  a  dull 
ache  to  one  of  great  intensity.  It  is  generally  reflected  to  the 
ovarian  region,  on  one  or  both  sides,  or  it  may  be  felt  alternately 
on  either  side.     "It  comes  on  about  the  twelfth  to  the  fourteenth 


736 


PAIN   IN    THE    FEMALE    GENITALIA 


day  after  cessation  of  the  menses.  It  lasts  for  a  day  or  two,  is 
often  accompanied  by  a  discharge  of  clear  fluid,  and  is  followed 
by  a  period  of  rest  or  complete  cessation  of  pain  np  to  the  onset 
of  the  next  period"  (Addison).  Change  of  position  does  not 
influence  the  intensity  or  character  of  the  pain.  On  examination, 
in  many  cases,  no  lesion  can  be  found. 


i?rL 


&?  00  3«o 
SACRAL 


Y 


Fig.  170. — Areas  of  Hyperalgesia  in  a  Woman  Two  Months  Pregnant. 

They  represent  the  10th  and  11th  dorsal  zones  of  Head.  The  maximum 
point  of  tenderness  is  in  the  10th  dorsal.  The  zones  did  not  e:itend 
uninterruptedly  around  to  back.  Tenderness  and  hyperalgesia  were 
present  over  the  corresponding  spines.  These  areas  of  hyperalgesia 
very  likely  are  due  to  traction  exerted  on  the  ovary  and  tube  of  the 
left  side  by  adhesions. 


Pregnancy. — In  a  normal  woman  pregnancy  is  entirely  free 
of  pain ;  yet,  it  is  common  for  the  physician  to  be  troubled  by  the 
complaints  of  his  patients  who  are  with  child.  The  causes  of 
pain  during  the  gi-avid  state  are : 

(1)  Pressure  upon  adjacent  and  associated  organs,  as  the 
tubes,  or  ovaries;  (2)  traction  on  adjoining  structures  by  adhe- 
sions; (3)  the  weight  of  the  organ  itself,  which,  even  though  nor- 
mal, may  drag  upon  neighboring  structures  and  produce  discom- 
fort and  distress;  (4)  in  some  cases,  the  projection  of  a  fetal  part 


UTERINE   PAIN  737 

into  the  uterine  wall;  (5)  intestinal  coils  may  drop  beneath  the 
uterus,  causing  a  partial  strangulation;  (6)  should  the  ovary  be 
cirrhotic,  the  corpus  luteum,  when  it  begins  to  anlarge,  is  com- 
pressed by  the  nondistensible  .connective  tissue,  and  dull,  aching 
pain  in  the  ovarian  zone  results;  (7)  partial  obstruction  to  the 
bowels  may  occur  during  pregnancy,  owing  to  some  of  the  intes- 
tinal coils  being  caught  between  the  uterus  and  the  surrounding 
parts;  (8)  obstruction  to  one  or  both  ureters  may  occur  from 
pressure  by  the  uterus,  and  thus  hydronephrosis,  with  its  conse- 
quent pain,  may  result. 

The  case  given  below  illustrates  the  production  of  pain  due 
to  a  partial  obstruction  of  the  bowels.  It  might,  also,  be  taken 
as  an  example  of  pains  produced  by  ovarian  and  uterine  conges- 
tion, the  pains  early  in  pregnancy  being  due  to  the  congestion,  the 
colicky  attacks,  later  in  the  pregnancy,  being  the  result  of  intes- 
tinal colic.  The  early  j)ains  of  which  the  patient  complained 
began  about  the  second  week  of  pregnancy  and  continued  inter- 
mittently. They  were  colicky  in  type  and  were  located  in  the  lower 
abdomen.  The  individual  attack  was  produced  by  the  patient's 
moving,  especially  by  her  turning  on  the  right  side.  During  the 
attack  she  was  doubled  up,  with  the  knees  flexed,  and  the  abdo- 
men was  tense  and  rigid.  The  hands  were  clinched  and  were 
pressed  tightly  into  the  suprapubic  region.  The  face  was  drawn 
and  the  eyes  closed.  The  individual  attacks  lasted  about  three 
minutes. 

These  colics  appeared  at  irregular  intervals,  ranging  from  a 
few  days  to  one  week;  sometimes  they  appeared  more  frequently, 
several  in  a  day.  After  being  present  for  six  weeks,  they  disap- 
peared and  the  patient  then  had  neither  pain  nor  colic.  A  vaginal 
examination  disclosed  a  retroflected,  enlarged  uterus,  about  two 
months  pregnant.  The  attacks  ceased  when  the  uterus  rose  above 
the  pelvic  brim. 

It  is  just  possible  that  in  this  patient  a  part  of  the  intestine 
had  been  caught  under  the  displaced  uterus,  and  that  its  lumen 
was  constricted,  the  severe  colic  of  which,  at  times,  the  patient 


738 


PAIN    IN    THE    FEMALE    GENITALIA 


complained  being  due  to  the  effort  of  the  intestine  to  force  its 
contents  beyond  the  constricted  portion. 

Childbirth. — Like      menstruation,       childbirth       naturally 
should  be  a  painless  j^rocess.      It  is   only   as   culture   advances 


Fig.  171. — Phenomena  Accompanying  Tubal  Disorders. 

The  uterus  was  at  this  time  above  the  pelvic  brim  and  the  ovary  was  free 
of  its  compression,  yet  the  tube  in  the  meantime  evidently  has  become 
injured  and  caused  the  above  phenomena.  Hyperalgesia  was  absent. 
A  few  weeks  after  the  above  phenomena  was  defined,  all  pain  and  dis- 
comfort ceased,  and  the  patient  had  a  normal  delivery. 

A — Area  of  local  tenderness,  also  area  of  pain  to  deep  pressure.  Superficial 
pressure  is  not  painful,  neither  is  muscular  pressure. 

B — Area  of  maximum  tenderness  to  deep  pressure. 

C — Area  of  pain  to  deep  pressure. 

D — ^Area  of  maximum  tenderness. 

that  the  labor  becomes  painful,  for  in  women  of  primitive  races 
pain  is  absent.  Savages  of  a  low  degree  of  civilization  are  gen- 
erally but  little  troubled  by  parturiency.  The  reason  is  that, 
although  among  primitive  people  the  contractions  of  the  uterus 
are  as  severe  during  childbirth  as  they  are  among  civilized  races, 
yet,  because  of  the  easy  dilatation  of  the  cervix,^  they  do  not 
1  Why  this  should  be  is  as  yet  unexplained. 


UTERINE   PAIN  739 

suffer  pain.  Among  observers  it  is  generally  agreed  that  pain 
of  uterine  contraction  is  not  due  to  the  contraction  of  the  muscle 
itself,  but  is  the  result  of  the  restraint  of  this  functional  activity 
by  cervical  obstruction.  This  cervical  obstruction  is  not  so  promi- 
nent among  primitive  people ;  therefore  they  have  less  pain. 
When  dilatation  of  the  cervical  segment  occurs  easily,  pain  is 
absent. 

At  the  present  time,  though  rare,  pain  may  be  entirely  absent 
during  labor.  Allen  explains  this  absence  of  pain  as  being  due 
to  the  relaxation  of  the  parts  by  nature,  while  Young  claims 
that  sometimes  at  the  acme  of  labor  there  is  a  physiological  anes- 
thesia. A  peculiarity  that  has  been  noted  of  the  pains  occurring 
during  labor  is  that,  instead  of  being  in  the  normal  locations,  they 
may,  as  in  a  case  seon  by  the  author,  be  radiated  from  the  thigh 
to  the  knee.  In  this  case  the  pains  were  excruciating  and  occurred 
synchronously  with  the  uterine  contraction,  as  Avas  verified  by  ab- 
dominal palpation.  In  this  respect  the  words  of  Granville,  whose 
remarks  hold  true  to-day,  may  be  quoted.     He  says: 

"Sensations  of  pain  experienced  by  the  parturient  woman  are 
not  invariably  synchronous  with  what,  for  want  of  a  better  name, 
we  term  the  pains  of  labor;  and  from  this  and  other  premises, 
for  example,  the  circumstance  that  they  are  commonly  referred 
to  regions  more  or  less  remote  from  the  contracting  uterus,  or  the 
dilating  external  passages,  in  which  the  real  seat  of  pain  might 
have  been  supposed  to  be  located,  I  deducted  that  the  pain  attend- 
ant on  labor  is  neuralgic  in  character." 

Labor  pains,  when  present,  are  as  a  rule  first  felt  as  a  drag- 
ging or  aching  in  the  back,  low  down  in  the  lower  lumbar  region. 
In  some  there  is  present  a  sensation  as  though  the  back  were 
breaking.  At  this  time  (the  first  stage  of  labor)  the  pain  corre- 
sponds to  the  early  stages  of  cervical  dilatation.  Later,  when  the 
uterus  commences  to  contract  and  the  cervix  begins  actively  to 
dilate,  pain  is  felt  over  the  sacrum  and  coccyx  in  the  second, 
third,  and  fourth  sacral  areas,  and  sometimes  in  the  first  and 
second  sacral  areas  (Head).  When  the  cervix  has  dilated,  and 
the  contractions  are  forcing  the  head  through  the  pelvis,  the  re- 


740 


PAIN   IN    THE    FEMALE   GENITALIA 


ferred  pains  are  felt  in  the  tenth,  eleventh,  and  twelfth  dorsal 
and  first  lumbar  areas.  These  are  the  areas  in  which  pain  is  felt 
post  partum,  when  the  uterus  is  forcing  out  of  its  cavitj  the 
residual  clots. 

After    labor    and    during   the    puerperium,    if    subinvolution 


A— -/- 


Fig.   172. — Areas  of  Referred  Pain  in  a  Case  of  Labor.    (Head.) 
a — Dilatation  in  the  second  stage  of  labor.    The  pain  is  in  the  11th  dorsal 

segment  and  is  due  to  contraction  of  the  uterus. 
B — Hyperalgesia  is  present  in  the  10th,  11th,  12th  dorsal,  1st  lumbar  and 
3d  sacral,  posteriorly  present  after  the  effort  of  the  uterus  to  expel 
post-partum  clots. 

should  occur,  a  feeling  of  weight  and  of  dragging  is  felt  in  the 
pelvis. 

Inflammation  of  the  Uterus. — Inflammation  may  occur  in  the 
lining  structure  (endometrium,  endometritis),  the  contracting  por« 
tion  (metrium,  metritis),  and  the  inclosing  structures  (perito- 
neum, broad  ligaments,  peri-  and  parametritis). 


UTERINE   PAIN  741 

Endometritis. — ^A  pronounced  inflammation  of  the  endo- 
metrium can  hardly  take  place  without  involving  the  next  adjacent 
structure  (metrium),  so  that  the  pain  due  to  a  severe  endometritis 
partakes  more  or  less  of  the  character  of  the  pain  due  to  a  metritis, 
and  if  the  inflammation  is  severe  and  involves  the  peritoneum, 
the  pain  has  also  the  characteristics  of  that  due  to  peritonitis. 
Ordinarily,  the  endometrium  has  no  pain  nor  touch  sensation,  but 
when  inflamed  it  becomes  very  sensitive.  This  is  of  great  diag- 
nostic value,  and  tenderness  (endometrial)  should  be  searched  for 
in  endometric  inflammatory  states.  This  tenderness  may  be  dem- 
onstrated by  means  of  a  sound  (Winter). 

The  sound  must  not  be  too  large,  and  should  be  carefully  in- 
troduced through  a  previously  dilated  cervix,  and  search  should 
be  made  for  the  sensitive  spots.  When  the  sound  touches  such  a 
spot  the  pain  may  be  so  severe  that  the  woman  "cries  out,  shrinks 
from  the  sound,  or  faints."  Should  pain  be  severe  only  on  the 
introduction  of  the  sound,  and  on  moving  it  with  sufficient  force 
to  disturb  the  relations  of  the  uterus  to  the  surrounding  tissues, 
and  not  present  on  gentle  manipulation,  peri-  or  parametritic 
inflammation  should  be  diagnosed.  That  the  endometrium  has 
pain  sensation  in  a  normal  case  can  hardly  be  admitted  (Roth- 
rock),  though  in  the  presence  of  inflammation,  the  adjacent  layer 
may  be  so  involved  by  the  inflammatory  process  that  it  becomes 
irritable  and  responds  to  any  irritation  with  a  sensation  of  pain. 
It  is  noticeable  that  the  pain  sensation  in  endometritis  of  ordi- 
nary severity  is  never  localized  to  the  area  of  its  production,  but 
is  always  referred;  but  should  the  inflammation  be  severe,  and 
perimetritis  result,  and  the  peritoneum  become  involved,  espe- 
cially if  the  inflammation  occurs  near  the  cervix  in  the  area  sup- 
plied by  the  spinal  nerves  the  pain  is  localized  to  the  area  of  its 
production. 

Endometritis  also  causes  pain,  having  somewhat  the  charac- 
teristics of  labor  pain;  this  pain  is  caused  by  the  same  factors 
that  produce  labor  pains,  namely,  the  contraction  of  the  uterine 
muscle,  excessive  in  the  endeavor  to  force  foreig-n  material  from 
the  cavity  of  the  uterus.     The  pain  is  most  severe  at  the  time  of 


742  PAIN   IN   THE   FEMALE   GENITALIA 

the  menses,  though  it  does  not  necessarily  appear  at  this  time, 
but  may  come  on  at  any  time  that  the  secretions  collect  to  such 
an  extent  that,  in  the  presence  of  a  stenosed  cervix,  their  expul- 
sion requires  forcible  uterine  contractions  which  are  very  painful. 

The  pain  of  endometritis  is  worse  on  standing  than  on  lying 
down.  Tenderness  on  palpation  is  not  present  unless  the  metrium 
and  the  surrounding  tissues  are  involved.  When  this  occurs, 
abdominal  and  bimanual  palpation  are  very  painful.  If  peritoni- 
tis has  set  in,  pressure  in  the  pouch  of  Douglas  produces  severe 
pain.     Likewise,  rectal  palpation  is   very  painful. 

Later,  as  a  result  of  these  inflammatory  states,  adhesions  form 
and  pain  results  from  their  drag  and  pull.  The  areas  of  reference 
of  these  pains  have  been  described. 

Cervicitis. — Erosions  of  the  cervix  cause  pain  either  through 
the  sympathetic  or  the  cerebrospinal  systems.  When  the  sympa- 
thetic is  involved,  the  pain  is  referred  to  the  area  of  distribution 
of  the  second  or  third  sacral  segments,  but  when  the  cerebrospinal 
is  involved  the  pain  is  referred  generally  through  the  branches 
of  the  pudic  to  the  perineum,  or  to  the  bladder.  When  the  lat- 
ter reference  occurs,  there  is  painful  and  frequent  urination. 
The  involvement  of  adjacent  nerves  is  probably  the  result  of  a 
lymphangitis  which  has  spread  from  the  erosions  into  the  peri- 
uterine fascia. 

Diagnosis  of  Endometritis. — The  following,  which  are  gen- 
erally present,  may  aid  in  the  diagnosis  of  endometritis : 

(1)  Hemorrhage;  eliminate  carcinoma,  myomata,  and  tubal 
inflammations,  all  internal  disorders  producing  it,  or  local  circu- 
latory derangements,  such  as  extrauterine  pregTiancy,  obstruction 
to  the  return  flow  by  tumors,  etc.,  and  it  is  safe  to  say,  in  the  ab- 
sence of  menstruation,  that  it  is  due  to  endometritis. 

(2)  The  pain  of  endometritis  is  somewhat  characteristic  in 
that  it  is  much  worse  at  the  time  of  menstruation. 

(3)  Discharge  of  inflammatory  products  and  endometrial 
shreds  from  the  uterus.  The  variety  of  endometritis  is  decided  by 
the  history,  the  onset,  the  discharge,  and  the  course. 

Ulceration  of  the  cervix,  unless  it  is  deep  and  has  produced  a 


UTERINE   PAIN  743 

pelvic  lymphangitis,  causes  no  local  pain,  but  a  reflected  pain  is 
felt  in  the  region  over  the  sacrum  and  the  coccyx  and  is  fre- 
quently localized  to  a  spot  immediately  dorsal  to  the  anus.  This 
spot  is  also  very  tender  to  the  touch. 

Metritis. — In  inflammation  of  the  muscular  layer  of  the 
uterus  pain  may  be  due  to  the  contraction  of  the  uterine  muscles, 
or  to  the  irritation  of  the  nerve  terminals  by  the  toxic  products 
of  the  inflammatory  process.  It  may  also  be  due  to  the  pressure 
exerted  upon  the  terminal  nerve  filaments  by  the  inflammatory 
products.  These  pains  are  referred  to  the  zone  areas  associated 
with  the  uterus  (see  Fig.  168).  Another  cause  of  pain  production 
is  the  spread  of  the  inflammation  to  the  peritoneum  with  involve- 
ment of  the  parietal  layer.  These  causes  are  active  only  in  the 
acute  cases,  for  as  a  rule  chronic  metritis  is  without  pain  (Theil- 
haber). 

New  Growths  of  the  Uterus. — New  growths  are  either  benign 
or  malignant.  Benign  growths  are  not  painful  unless  they  block 
the  cervical  canal ;  when,  during  contraction  of  the  musculature, 
pain  of  the  type  of  a  labor  pain  is  felt.  This  pain  persists  in  rhyth- 
mical periods  until  the  mass  has  been  expelled  or  until  the  canal 
has  become  free.  The  pain,  naturally,  would  be  greater  at  the 
time  of  the  menstrual  periods.  Growths  may  also  press  upon  ad- 
jacent structures  and  interfere  with  their  function  and  so  cause 
pain.  They  may  also  press  upon  the  lumbar  and  sacral  nerves 
and  cause  pain  which  is  referred  to  the  peripheral  distribution 
of  these  nerves  in  the  back  and  legs  (Donald  and  Lickley).  Pain 
due  to  pressure  from  growths,  as  a  rule,  is  constant. 

Malignant  growths  toward  the  end  are  always  painful,  but 
early  in  their  course  are  usually  free  from  pain.  Pain  occurs 
only  when  the  growth  makes  pressure  upon  the  surrounding  struc- 
tures, or  interferes  with  the  emptying  of  the  uterus,  or  when  the 
tumor  cells  invade  the  nerve  trunks.  Kundrat  has  shown,  in  the 
case  of  carcinoma,  that  the  nerve  trunks  become  infiltrated  with 
cancer  cells.  In  other  cases  pain  may  be  due  to  the  absorption 
of  toxins  or  to  the  extension  of  the  inflammatory  growths  (Roth- 
rock).    In  all  these  conditions,  when  the  growth  is  in  the  fundus 


744  PAIN   IN   THE   FEMALE   GENITALIA 

or  deep  in  the  cervix,  referred  pain  in  the  skin  area,  associated 
with  the  particular  part  of  the  genitalia  involved,  is  present. 
Should  the  cervical  canal  become  obstructed,  typical  uterine  colic 
pain  appears.  Pain  seems,  when  present,  to  be  more  often  felt 
on  the  left  side  (Champney). 

Fibroids  of  the  uterus  are  fairly  common.  They  announce 
their  presence  by  two  varieties  of  pain :  ( 1 )  a  periodic  pain  which 
appears  before  each  menstrual  period  and  is  relieved  by  menstrua- 
tion, and  (2)  an  intermittent  pain,  which,  in  the  case  of  intra- 
uterine fibroids,  accompanies  the  menstrual  flow.  It  may  also  ap- . 
pear  at  other  times.  Some  fibroids  have  also  been  known  to  extend 
into  the  pelvis,  and,  by  pressing  on  the  lumbar  and  sacral  plexis, 
to  give  rise  to  pain  in  the  distribution  areas  of  the  involved  nerves. 
The  great  sciatic  is  most  frequently  affected,  and  pain  in  its  dis- 
tribution area  is  common  (Wilson,  361). 

In  cancer  of  the  uterus,  out  of  sixty-seven  cases  pain  was  the 
first  symptom  to  appear  in  twelve  (Craig)  ;  leucorrhea,  in  forty- 
five,  and  hemorrhage,  in  twenty-two. 

FALLOPIAN   TUBES 

Pain  due  to  disease  of  the  Fallopian  tubes  may  result  from 
(a)  distention  of  the  tubes;  (b)  inflammation  of  the  tubes;  (c) 
adhesion  of  the  tubes  to  neighboring  structures. 

Tubal  Conditions  Causing  Pain. — All  who  practise  medicine, 
and  particularly  surgeons,  are  familiar  with  hydrosalpinx,  a  con- 
dition in  which  the  Fallopian  tubes  contain  a  considerable  amount 
of  clear  serum.  In  these  cases  the  uterine  and  the  fimbriated 
extremities  of  the  tubes  are  blocked,  so  that  it  is  impossible  for 
the  fluid  to  be  discharged.  Pain  may  follow  this  stagnation, 
though  the  swelling  in  many  cases  reaches  a  considerable  size 
before  its  presence  becomes  intolerable ;  in  fact,  it  may  never 
cause  pain.  Yet,  because  of  the  pressure  exerted  upon  adjacent 
structures,  or  because  of  the  active  inflammation  which  is  pres- 
ent, pain  is  frequently  a  prominent  symptom.  If  the  pain  l>e 
due  to  dragging  or  to  pressure  on  adjacent  structures,  it  may  be 


FALLOPIAN   TUBES  745 

eased  by  the  patient's  assuming  a  counter-posture.  If  it  be  due 
to  inflammation,  the  increase  in  j3ulse  rate  and  elevation  of  tem- 
perature will  help  to  define  the  lesion.  When  the  tube  is  inflamed, 
the  resulting  pain  is  either  reflected  (Head  zone,  see  figaire)  or 
is  localized  to  the  area  in  which  it  is  produced.  In  the  latter  in- 
stance the  pain  is  felt  in  the  lower  iliac  region,  and  is  due  to  the 
inflammation,  communicated  to  the  parietal  peritoneum  from  the 
diseased  tube.  It  is  of  a  burning,  stabbing  character,  and  may 
be  very  severe. 

If  the  pain  is  the  result  of  an  acute  hyperemia,  it  is  of  a  throb- 
bing character,  while  that  due  to  chronic  inflammation  is  of  a  dull, 
aching  type.  All  inflamed  sensitive  tissues  are  tender  to  pressure ; 
therefore,  pressure  on  the  tubes  will  also  be  painful.  This  pres- 
sure on  the  tubes  may  be  exerted  by  two  methods.  The  first  is  the 
bimanual,  by  which  pressure  is  made  between  one  hand  placed 
over  the  abdomen  and  the  index  or  the  first  two  fingers  of  the 
second  hand  inserted  into  the  vagina.  With  the  fingers  in  the 
vagina,  the  uterus  can  be  rocked  to  either  side.  If  on  this  mo- 
tion pain  is  produced  it  may  be  surmised  that  inflammation  is 
present.  When  the  uterus  is  thrown  to  the  side  away  from  the 
inflamed  tube,  pain  is  the  result  of  the  traction  and  stretching 
which  ensue,  while  if  it  is  thrown  against  the  inflamed  tube, 
pain  results  from  the  pressure.  The  pressure  of  the  uterus 
against  the  inflamed  tube  is  much  more  painful  than  is  the  trac- 
tion away  from  it. 

Should  chronic  salpingitis  be  present,  pain  may  be  produced 
by  grasping  the  tube  between  the  examining  fingers,  thus  making 
pressure  directly  upon  it.  Sometimes,  in  pyosalpinx,  if  the  ex- 
amination has  been  rough,  some  of  the  pus  may  be  pressed  out 
of  the  end  of  the  tube,  and  a  localized  peritonitis  results.  This 
is  indicated  at  the  time  by  a  severe  pain,  persisting  after  the 
examination.  It  may  be  accompanied  by  an  elevation  of  tem- 
perature and  a  rise  in  the  pulse  rate.  Spontaneous  rupture  of  a 
tube  through  its  fimbriated  extremity  is  very  rare. 

In  tubal  inflammation  all  functional  acts  which  in  any  way 
cause  a  changed  relationship  between  the  tubes  and  the  surround- 


746  PAIN    IN    THE    FEMALE    GENITALIA 

ing  functioning  structures  are  very  painful.  In  many,  micturi- 
tion and  defecation  are  productive  of  much  pain ;  indeed,  they 
may  become  so  painful  that  the  patients  voluntarily  inhibit  them- 
selves from  performing  the  acts.  Constipation  and  retention  of 
urine  necessarily  result.  Micturition  is  not  so  painful  when  the 
inflammation  is  confined  to  the  tube,  but  becomes  extremely  so 
when  the  bladder  itself  is  involved  in  the  inflammatory  process. 
These  disturbances  produce,  in  addition  to  those  already  present, 
their  own  particular  form  of  pain. 

Sometimes  tubal  inflammation  causes  uterine  colic  (Winter 
and  Clark).  In  such  cases  exacerbations  of  pain,  occurring  gen- 
erally prior  to  the  periods,  are  frequent.  Should  pain  be  present 
in  the  ovarian,  tubal,  and  uterine  areas  at  the  same  time,  it  in- 
dicates an  involvement  of  all  these  associated  structures.  In  a 
case  of  gonorrheal  salpingitis,  Saenger  (362)  thought  the  pain 
was  due  to  the  excitation  of  peristalsis  by  the  inflammation 
present. 

As  a  result  of  tubal  inflammation,  adhesions  are  formed  and 
resist  subsequent  distentions  of  the  tube,  and  are  accountable  for 
a  large  share  of  the  resulting  pain,  particularly  so  if  the  disten- 
tion is  accompanied  by  certain  functional  acts  that  in  the  ordinary 
course  of  events  would  be  painless.  However,  tubal  swelling, 
alone,  without  the  presence  of  adhesions,  may  be  painful.  How 
large  it  may  become  before  it  is  painful  depends  particularly  upon 
the  local  conditions.  A  tube  in  a  free  and  clear  pelvis  may  reach 
a  much  greater  size  without  discomfort  than  if  it  were  in  a  pelvis 
filled  with  pelvic  exudate  and  bound  with  adhesions.  In  some 
the  tube  may  reach  the  size  of  an  orange  without  causing  great 
discomfort,  while  in  others  a  very  small  swelling  will  produce  the 
utmost  distress. 

Extrauterine  Pregnancy. — Extrauterine  pregnancy  (tubal  or 
tuboovarian)  may  cause  no  pain  unless  a  rupture  or  a  partial  rup- 
ture occurs,  and  bleeding  into  the  peritoneal  cavity  takes  place. 
This  complication  may  follow  a  vaginal  examination,  or  it  may  be 
the  result  of  sudden  motion  or  of  forcible  bending  or  flexion  of  the 
body.     It  is  indicated  by  severe  and  agonizing  pain,  generally  in 


■ 

DIFFERENTIAL  DIAGNOSIS    OF  EXTRAUTERINE  PREGNANCY 

EXTRAUTERINR 

Salpingitis                                          Appendicitis 

Peritonitis,   Perforative 

Abortion 

Pain. 

Comes   on  generally    after    exer- 
tion, and  is  sudden  in  onset.    The 
pain  is  most  intense  and  is  local- 
ized in  the  lower  abdomen.    In 
some  cases  a  pain  is  also  felt  in 
the  shoulder  of  the  same  side. 

Pain   may   be   gradual   in   onset, 
though  in  some  cases  it  is  very 
acute.     Begins  in  the  lower  part 
of  abdomen.     In  acute  cases  the 
pain  is  sudden  in  onset  and  is  local- 
'  ized  in  the  tubal  areas.   In  general- 
ized peritonitis  pain  is  absent. 

Generally    sudden    in    onset.     At 
first  is  in  the  midline.     Later  it 
passes  over  to  the  right  iliac  fossa. 

Sudden  in  onset.  Continu- 
ous. Referred  to  lower  ab- 
domen. 

Pf.',^..r^embles     that    of 
childbirth.     Comes  on  at 
mtervals,  and  is  associated 
with  uterine  hemorrhage. 

Vomiting. 

Frequent    and   synclironous   with 
the  pain. 

Vomiting  is  a  late  symptom. 

Vomiting  is  an  early  symptom. 

Vomiting  is  an  early  symp- 
tom. 

No  vomiting  as  a  rule. 

Pulse. 

At  first,   because  of  shock,  may 
not  be  gi-eatly  increased  in  rapid- 
ity.      After  the  primary  shock, 
the  rapidity  is  not  very  great  until 
the  amount  of  blood  lost  becomes 

Generallv  rapid  in  acute  lesions. 
In   chronic  lesions    generally  no 
change. 

Generally    very    rapid    in    acute 

Generally  very  rapid.  Typ- 
ically small  and  thready. 

Pulse  may  be  slightly  in- 
crea.sed.      In    some    cases, 
owing  to  fright  and  exces- 
sive loss  of  blood,  it  may  be 
very  rapid. 

Tumor. 

Very  sensitive  and  tender  and  lies 
to  one  side  of  the  uterus.     Is  con- 
stantly increasing  in  size.    After 
rupture,  when  a  hematocele  has 
formed,  the  tumor  mass  of   the 
uterus  rapidly  increases  in  eize, 
and  is  soft  and  boggy. 

Painful  swelhng  to  one  side  of  the 
uterus.     Generally   the   uterus  is 
fixed  and  is  not  freely  movable. 
Tumor  is  often  bilateral. 

Tumor  in  acute  appendicitis  can 
rarely  be  defined  because  of  the 
excessive  tenderness  and  rigidity 
of  the  abdominal  muscles.    Per- 
cussion sometimes  elicits  tender- 
ness when  palpation  fails  to  do  so. 
If  an  abscess  has   formed,  it  can 
be  felt  by  vaginal  examination. 

Tumor  absent. 

Tumor  mass  is  absent. 

History. 

Of  pregnancy,  with  enlargement  of 
the  uterus  which  is  not  in  propor- 
tion to  the  stage  of  the  pregnancy. 

History  of  recent  childbirth  or  of 
a  vaginal   infection.        Often   no 
accountable  cause  is  present. 

History  of  a  previous  attack  may 
be  present. 

History  of  appendiceal  in- 
flammation. Intestinal  in- 
flammation; typhoid,  tu- 
bercular. 

History  of  pregnancy. 

Temperature. 

No  clevatiun.      GcruTally  normal. 

Rise  of  temperature. 

Generally  sudden,  progressive  rise. 

At  first,  as  a  rule,  is  not  so 
high.  Shock  with  a  low 
temperature  may  at  first  be 
present. 

Normal. 

Uterus. 

Enlarged. 

Not  enlarged. 

Not  enlarged. 

Not  enlarged. 

Enlarged. 

Blood. 

Hemoglobin  low  and  decreasing. 
Red  and  white  cells  both  reduced. 

Hemoglobin     high;     whites     in- 
creased ;  reds  normal. 

Leukocytosis.        Hemoglobin  and 
red  cells  normal. 

Leukocytosis.  Hemoglobin 
and  red'  cells  normal. 

In   cases  of  great  loss  of 
blood  hemoglobin,  reds  and 
whites  may  be  all  decreased. 
In  other  cases   no  marked 
change. 

Abdomen. 

Fluid,  if  the  hemorrhage  has  been 
very  great,  may  be  elicited  on  pal- 
pation and  percussion.     Puncture 
of  the  posterior  vaginal  vault  with 
an    aspirating   needle  frequently 
will  at  once  reveal  condition.     A 
mass  is  present  in  pelvis.    Rigid- 
ity of  abdominal  muscles  may  be 
present.      No  change  in  intestinal 
peristalsis. 

No  ,fluid,  but  a  mass  connected 
with  the  uterus  may  be  felt  in  the 
pelvis.     Rigidity    of    the    lowest 
se^ent  of  the  rectus.     No  change 
in  intestinal  peristalsis. 

No  fluid  present.      Mass  in  right 
iliac   region    may    be    felt    when 
abscess  has  formed.    No  change  in 
peristalsis.    LocaUzed  rigidity  over 
lower  segment  of  rectus. 

Free  fluid  may  or  may  not 
be  present.  Mass  absent. 
Peristalsis  diminished. 

Fluid  absent.     Mass   (en- 
larged uterus)  can  often  be 
demonstrated.    No  abdom- 
inal   rigidity.      Peristalsis 
normal. 

OVARY  747 

the  iliac  region  of  the  side  involved,  though  it  may  be  spread 
over  the  entire  lower  abdomen.  In  same  cases  the  pain  is  re- 
ferred to  the  shoulder.  In  these  cases  it  is  possible  that  the 
blood  may  extend  as  high  as  the  diaphragm  and  so  irritate  it; 
this  irritation,  in  turn,  is  transmitted  through  the  phrenic  to  the 
supraacromial  nerve,  and  so  causes  pain  to  be  referred  to  the 
shoulder. 

It  is  rather  surprising  to  note  the  small  quantity  of  blood  which 
■produces  such  a  severe  sensory  reaction.  In  many  cases  the  pres- 
ence of  an  ounce  or  two  of  free  blood  in  the  peritoneal  cavity  will 
cause  the  most  severe  distress. 

The  pain  probably  represents  the  prostration  of  the  perito- 
neum to  the  traumatism  of  the  hemorrhage.  In  hemorrhage  pro- 
duced by  the  slipping  of  a  ligature  from  the  stump,  following  an 
ovariotomy,  no  pain  is  present,  probably  for  the  reason  that  the 
peritoneum,  having  already  been  subject  to  the  shock  and  trauma- 
tism of  an  abdominal  operation,  is  not  capable  of  again  responding 
when  the  hemorrhage  occurs  (Richardson). 

Ruptured  tubal  pregnancy  may  be  confused  with  (Crossen)  : 
(1)  hemorrhage  from  the  ovary,  (2)  tuboovarian  hemorrhage,  (3) 
fulminating  pelvic  edema,  (-i)  gonorrheal  salpingitis,  (5)  miscar- 
riage, occurring  in  a  patient  who  has  an  ovarian  tumor,  (6)  preg- 
nancy with  hydatidiform  mole,  (7)  rupture  of  a  pus  tube,  (8)  ap- 
pendicitis, (9)  strangulation  of  internal  hernia,  and  (10)  perfora- 
tive peritonitis. 

In  extrauterine  pregnancy  intense,  lancinating  pain  in  the 
lower  part  of  the  rectum  is  at  times  complained  of.  The  cause 
of  this  pain  may  be  adhesion  between  the  gestation  sac  and  the 
rectum  (Boldt). 

OVARY 

"No  pain  is  caused  during  pelvic  examination  by  taking  a  nor- 
mal ovary  between  the  fingers  and  thus  making  pressure  upon  it, 
but  a  peculiar  sickening  sensation  is  experienced,  somewhat  of 
the  same  character  as  is  felt  by  the  male  when  his  testicle  is 
s(jueezed, 


748  PAIN    IN    THE    FEMALE    GENITALIA 

Local  Point  of  Pain. — Head  gives  the  area  of  cutaneous  hyper- 
algesia for  ovarian  disorders  as  that  of  the  tenth  dorsal  segment 
(see  Fig.  173)  and  he  mentions  two  points  of  maximum  tender- 
ness, one  in  the  small  of  the  hack  over  one  or  more  lumbar  verte- 
brae, and  the  other  at  a  point  a  little  below  and  external  to  the  um- 
bilicus on  the  same  side  as  the  ovary  which  is  at  fault.  It  seems 
very  odd  that  Morris  should  have  called  attention  to  this  point 
during  the  past  few  years,  as  a  sign  of  oophoritis  or  of  disease  of 
the  appendages.  He  claims  that  in  disease  of  the  ovaries  or  ap- 
pendages there  is  a  spot  tender  to  pressure,  about  one  and  one- 
half  inches  down  from  the  umbilicus  and  one  inch  external  to 
the  midline  of  the  abdomen.  In  appendicitis  there  is  pain  on 
pressure  at  this  point,  but  it  is  present  only  on  the  right  side, 
while  in  ovarian  or  tubal  disease  the  pain  is  present  on  both  sides. 
Pain  from  the  ovary  has  also  been  known  to  be  reflected  to  distant 
points.  In  one  case  it  was  present  in  the  shoulder,  and  ran  do^vn 
the  left  arm. 

Causes  of  Pain. — The  causes  of  ovarian  pain  are:  (1)  pressure 
from  an  increased  cell  production,  (2)  structural  changes  in  the 
nerves  supplying  the  ovary,  (3)  functional  changes  in  the  nerves 
by  which  their  sensibility  is  greatly  increased  (McEvitt).^ 

Characteristics  of  Ovarian  Pain. — Cuthbert  Lockyear  (307, 
p.  1061)  gives  the  following  characteristics  of  ovarian  pain: 

(1)  It  is  referred. 

(2)  It  is  associated  with  superficial  or  surface  tenderness. 

1  Herman  (144)  says  that  the  point  that  is  commonly  pressed  upon  in 
eliciting  ovarian  tenderness  is  about  two  inches  internal  to  the  anterior  su- 
perior spine.  That  pressure  over  this  area  makes  pressure  on  the  ovary  is  very 
doubtful,  for  the  relationship  between  the  abdominal  wall  and  the  ovary  is  con- 
stantly changing  by  every  variation  of  intraabdominal  pressure,  and  by  every 
change  of  position  of  the  intraabdominal  organs,  so  that,  because  of  this 
mobility,  it  would  be  impossible  to  compress  the  ovary  even  by  pressure  on  the 
abdominal  wall,  applied  directly  over  the  ovary.  The  only  effect  would  be 
to  cause  a  slight  change  in  its  position.  Such  an  area  of  tenderness  is  also 
found  in  hysterical  men.  From  such  data  we  may  conclude  that  the  pain  is 
not  due  directly  to  the  ovary,  but  to  related  conditions  such  as  irritation  of  the 
peritoneum  from  inflammation  spreading  from  other  organs,  or  from  stretching 
due  to  traction  made  upon  the  peritoneum  by  ligaments  and  adhesions  joining 
it  to  abdominal  organs. 


OVARY  749 

(3)  It  tends  to  become  generalized  or  diffused. 

(4)  It  follows  the  lines  of  spinal  segmentation  and  not  of 
peripheral  nerves. 

(5)  It  is  associated  with  exaggerated  superficial  reflexes. 

(6)  It  is  closely  connected  with  the  neurasthenic  state. 
Ovarian  disorders  mav  cause  pain  in  distant  regions,  such  as 

headache,  which  is  frequent.  It  is  most  common  in  the  frontal 
region  and  is  worse  at  the  menstrual  period. 

The  diseases  of  the  ovarj^  causing  pain  are :  neuralgia,  dis- 
placement,  inflammation,   abscess,  and  new  growths. 

Neuralgia  of  the  ovary  is  possible,  but  generally,  when  ovarian 
pain  is  present,  it  is  due  to  structural  changes  in  the  ovary,  such 
as  occur  in  congestion  and  inflammation. 

Displacement  of  the  ovary,  or  prolapsus,  generally  produces 
pain  which  is  felt  in  the  ovarian  reference  areas.  When  displace- 
ment occurs,  vaginal  examination  will  show  the  ovary  to  be  in  a 
false  position.  If  adhesions  between  the  ovary  and  adjacent  or- 
gans have  formed,  the  traction  upon  the  adhering  organ  will 
cause  pain,  which,  as  a  rule,  is  referred  to  the  pain  area  of  the 
organ  adhering. 

Hernia  of  the  ovary  is  generally  associated  with  hernia  of 
other  organs,  and  is  not  especially  painful.  The  presence  of  an 
ovary  in  a  hernial  sac  may  be  surmised  from  the  peculiar  sickening 
sensation  which  is  produced  when  pressure  is  made  upon  the  sac. 

Hyperemia  of  the  Ovary. — Immediately  preceding  menstrua- 
tion, all  of  the  female  genital  organs  are  engorged  with  blood;  if 
they  are  normal,  this  engorgement  produces  no  disturbance,  ex- 
cept a  slight  physical  discomfort ;  but,  should  a  hypertrophy  or  a 
hyperplasia  of  the  connective  tissue  have  taken  place,  pain  results. 
This  pain  is  present  for  one  or  two  days  preceding  menstruation. 
It  is  due  to  the  constriction  and  pressure  upon  the  terminal  nerve 
filaments  of  the  ovarian  stroma  exerted  by  the  congested  tissues. 
After  the  blood  flow  is  well  established,  the  pain  quickly  disap- 
pears. The  congestion  may  be  so  intense  that  hemorrhage  into 
the  ovarian  stroma  occurs.  This  is  productive  of  very  intense 
and  throbbing  pain  in  the  region  of  the  ovary  or  in  the  area  to 


750  PAIN    IN    THE    FEMALE    GENITALIA 

which  ovarian  pain  is  referred.  It  is  characteristic  of  this  dis- 
order that  it  progressively  becomes  worse,  and  removal  of  the 
ovary  is  the  only  hope  of  relief. 

In  addition  to  the  passive  form  of  hyperemia,  pain  also  may 
be  due  to  the  active  variety.  One  of  these  forms  of  hyperemia  is 
due  to  bacterial  invasion.  Here  an  active  inflammation  has  taken 
place,  and  the  pain  which,  in  passive  congestion,  was  present  only 
preceding  menstruation  is  now  more  or  less  continuous,  and  is 
markedly  increased  during  the  menses.  As  may  happen  during 
any  intraperitoneal  visceral  disease,  the  inflammation  may  spread 
beyond  the  organ  of  its  origin  and  infect  the  adjacent  organs, 
especially  the  peritoneum.  Such  a  spreading  may  also  occur  in 
the  ovarian  inflammation.  The  referred  ovarian  pain,  as  well 
as  the  mild  local  tenderness,  is  now  much  increased  by  the  symp- 
toms of  the  peritonitis  arising  around  the  ovary.  The  most 
prominent  of  these  symptoms  is  excessive  tenderness  in  the  lower 
iliac  region.  The  patient,  who  previously  may  not  have  been 
compelled  to  take  to  her  bed,  now  gradually  avails  herself  of  such 
an  opportunity.  She  is  inclined  to  lie  flat  on  her  back  and  to 
draw  up  the  limb  on  the  affected  side;  or,  if  both  sides  are 
affected,  to  draw  up  both  limbs.  At  the  same  time  the  lower 
segment  of  the  rectus  muscle  on  the  diseased  side  becomes  quite 
rigid.  Should  the  inflammation  spread  further,  all  her  symp- 
toms are  aggi'avated.  She  now  lies  slightly  inclined  to  the  side 
involved,  with  the  limbs  drawn  up.  Breathing  is  restricted  and 
becomes  entirely  costal.  All  motion  is  abolished  and  the  patient 
is  content  to  stay  in  bed,  quiet  and  inactive.  Such  states  are  the 
forerunners  of  an  invalidism  that  may  become  chronic,  and  per- 
sist, even  after  the  original  cause  has  been  removed.  When  the 
acute  attack  subsides,  and  the  lesion  assumes  a  chronic  form,  the 
woman,  although  she  can  go  about  and  do  her  work  to  a  moderate 
degree,  is  subject  to  sudden  recurring  attacks  of  inflammation; 
perhaps  in  the  midst  of  festivities,  or  at  the  time  of  greatest 
need,  she  is  compelled  to  take  to  her  bed  until  the  acute  attack 
again  subsides.  In  any  case,  she  is  a  poor  unfortunate  creature, 
whose  life,  unless  she  is  relieved  by  surgical  measures,  becomes 


OVARY  751 

an  endless  series  of  periods  of  ease,  alternating  with  those  of  the 
most  intense  distress. 

The  pathology  clearly  shows  why  this  lesion  is  so  painful. 
An  ovary,  the  seat  of  chronic  inflammation,  generally  is  either 
sclerotic  or  cystic,  and  has  a  thickened  tunica.  An  examination 
will  disclose  that  nearly  all  of  the  normal  stroma  has  been  re- 
placed by  connective  tissue,  so  that  at  the  time  of  menstrual  or 
other  engorgement  there  is  no  room  for  expansion,  and  the  sensi- 
tive terminal  nerve  filaments  are  caught  between  the  swollen 
masses  of  tissues  and  are  subjected  to  a  severe  pressure.  This 
causes  pain.  The  greater  the  engorgement  the  more  severe  the 
pain.  Should  the  inflammatory  engorgement  continue,  and  con- 
nective tissue  form,  the  contraction  of  this  tissue  on  the  sensitive 
terminal  nerve  filaments  produces  the  pain.  As  this  pressure  is 
continuous,  the  pain  and  distress  become  constant.  Jessett  (300, 
p.  1059)  thinks  that,  in  cases  in  which  "the  capsule  of  the  ovary 
is  found  to  be  thickened  and  corrugated  with  fibrous  tissue  dip- 
ping down  into  the  ovarian  stroma,  and  in  which  a  single  cyst 
or  multiple  cysts  are  found  incorporated,  it  is  the  binding  down 
of  these  by  the  dense  capsule,  which  is  the  cause  of  pain."  Her- 
man, however,  thinks  that  sclerocystic  disease  of  the  ovary  is 
generally  free  from  pain  unless  it  is  associated  with  peritonitis. 
Following  inflammation,  adhesions  to  other  organs  may  form. 
These  adhesions  are  a  common  cause  of  pain  production.^ 

Abscess  of  the  Ovary. — If  the  pain  of  an  acute  inflammation 
of  the  ovary  does  not  subside  within  a  reasonable  time,  an  ab- 
scess formation  should  always  be  considered.  When  this  occurs, 
the  pain  becomes  greater  instead  of  less,  and  a  gradual  but  sure 
increase  in  the  local  tenderness  is  noticed.  At  the  same  time,  a 
mass  connected  with  the  uterus  and  slightly  movable  makes  its 

1  Heywood  Smith  (305,  pp.  1060-1061)  says  that  ovarian  disease  is  painful 
in  three  stages: 

(1)  "In  stage  of  congestion  through  tension  of  the  blood  vessels. 

(2)  "Thickening  of  the  stroma. 

(3)  "Indrawing  or  contraction  of  the  fibrous  stroma. 

"In  all  these  conditions,  the  tension  of  the  blood  pressure  at  the  men- 
strual molimen  is  the  cause  of  pain," 


752  PAIN   IN   THE   FEMALE   GENITALIA 

appearance  in  the  lower  iliac  region.  At  once  the  question  is  pre- 
sented :  Is  this  mass  the  ovary  or  is  it  an  inflammation  of  the  tube 
with  a  local  collection  of  pns  ?  To  answer  rightly,  it  is  necessary 
to  call  into  requisition  the  most  acute  diagnostic  skill.  A  diag- 
nosis, it  is  true,  may  be  easy  if  one  is  able  to  connect  the  inflam- 
matory mass  with  the  uterus,  such  as  is  possible  if  the  abscess  is 
tubal,  or  to  the  ovary,  if  the  abscess  is  ovarian. 

Some  slight  aid  in  diagnosis  of  the  exact  location  of  the  ab- 
scess is  furnished  by  the  different  areas  of  referred  pain;  but 
generally  it  may  be  stated  that  only  the  diagnostic  skill  of  the 
examiner,  combined  with  a  clear  and  almost  instinctive  method 
of  deductive  reasoning,  will  enable  him  to  arrive  at  a  correct 
conclusion.  After  all,  practically  it  makes  very  little  material 
difference  whether  the  abscess  is  of  the  ovary  or  of  the  tube. 
Inflammation  of  the  ovary,  with  abscess  formation,  demands  iden- 
tical treatment  with  inflammation  and  abscess  formation  of  the 
tube.  Both  produce  localized  pelvic  peritonitis  and  pus  forma- 
tion, the  symj)toms  of  which  have  been  described. 

Adhesions  of  the  ovary  frequently  follow  inflammation.  When 
they  form,  the  resulting  pain  is  related  to  the  functional  acts  of 
the  adhering  organ ;  for  instance,  micturition  causes  pain  when 
the  bladder  is  adherent  (this  is  rare)  and  defecation  is  painful 
when  the  rectum  is  affected.  In  all  cases,  an  ovary  which  is  sur- 
rounded by  adhesions,  as  a  rule,  has  been  so  badly  diseased  that 
functional  acts  of  its  own,  such  as  ovulation  or  the  congestion 
incidental  to  sexual  connection,  will  cause  pain. 

Tuberculosis. — A  tuberculous  ovary  is,  as  a  rule,  not  very  sensi- 
tive. A  characteristic  of  it  is  that  it  is  closely  approximated  to 
the  uterus  and  seems  glued  to  it  (Reed,  Martin). 

Enlarged  Uterus.- — Pressure  on  the  ovary  by  an  enlarged 
uterus  may,  in  some  rare  instances,  cause  pain.  In  some  cases  the 
pressure  hinders  the  return  blood  flow  from  the  ovary,  and  the 
pain  is  the  result  of  the  consequent  congestion. 

Relationship  of  Ovaries  and  Parotids. ^ — Swelling  of  the  ovary, 
and  pain  in  the  ovarian  region,  are  common  in  parotitis.  Like- 
wise, in  cases  of  swelling  and  inflammation  of  the  ovary,  pain 


OVARY  753 

and  swelling  may,  in  some  cases,  be  present  in  the  parotids.  It 
hardly  seems  possible  that  the  association  of  these  two  organs 
can  be  through  nerve  paths,  for  they  are  so  widely  separated  from 
each  other  and  each  derives  its  nerve  supply  from  unrelated 
nerves.  It  seems  more  than  likely  that  the  exciting  cause  is  a 
ferment,  elaborated  either  by  the  ovary,  or  the  parotid,  the  fer- 
ment of  the  one  producing  activity  in  the  other. 

Tumors  of  the  ovary  include  cysts  and  new  growths,  carci- 
noma, and  sarcoma. 

Cysts  of  the  Ovary. ^ — Cystic  disease  of  the  ovary,  unless  peri- 
toneal or  pressure  symptoms  have  developed,  is  without  pain 
(Herman,  Gallaban).  In  a  study  of  eight  large  ovarian  cysts 
Sampson  found  that  the  walls  of  all  were. insensitive  to  touch  and 
pain,  the  insensibility  to  pain  being  tested  by  cutting,  pinching 
and  clamping. 

However,  traction  on  the  pedicles  of  cysts  causes  pain,  which 
becomes  greater  as  the  traction  is  increased.  The  pain  is  usually 
felt  at  or  about  the  pelvic  brim,  but  if  the  traction  is  increased 
it  becomes  more  diffuse,  and  is  then  generally  felt  over  the  entire 
side  of  the  abdomen  or  in  the  back.  In  some  instances  it  may  be 
so  diffuse  that  the  patient  is  unable  to  localize  it.  Also,  if  the 
pain  be  severe,  nausea  may  occur.  Immediate  relief  of  both  pain 
and  nausea  follows  removal  of  the  traction. 

Clamping  or  pinching  of  the  pedicle  gives  contradictory  re- 
sults. In  some  cases  it  seems  to  cause  pain,  even  when  great  care 
is  exercised  to  avoid  all  traction  on  the  cyst  or  on  any  part  of 
the  parietal  peritoneum.  In  other  cases  the  pedicle  is  relatively 
insensitive  to  clamping,  cutting,  and  ligating,  if  these  are  ac- 
complished without  traction.  The  pain  from  pulling  or  twisting 
of  the  pedicle  seems  to  originate  from  the  traction  on  the  parietal 
peritoneum  and  the  retroperitoneal  tissues  of  the  side  and  back. 
The  pain  varies  according  to  the  force  of  the  traction,  and  is  felt 
in  the  back  or  side.  If  it  is  very  severe,  the  patient  may  be  unable 
to  locate  it.  When  the  traction  is  slight,  headache,  accompanied  by 
indefinite  abdominal  and  pelvic  pains,  may  result. 

As   stated   above,   twisting  of  the   pedicle   almost   invariably 


754  PAIN   IN   THE   FEMALE    GENITALIA 

causes  severe  pain.  This  is  in  accord  with  clinical  experience. 
The  pain  may  be  localized  in  the  side  or  in  the  back,  or  may  be 
very  diffuse,  and  is  frequently  accompanied  by  nausea.  There 
may  be  many  mild  attacks  of  pain,  due  to  slight  twisting  of 
the  pedicle,  which  is  quickly  relieved  by  a  shifting  of  the  posi- 
tion of  the  cyst  with  a  consequent  relief  of  pain.  A  sign  very 
characteristic  of  twist  of  the  pedicle  is  that  the  pain  is  very  much 
increased  when  the  patient  turns  from  one  side  to  the  other.  This 
is  due  to  the  rolling  over  and  dragging  on  the  twisted  pedicle,  by 
the  tumor  (Donald  and  Hickley).  Should  the  twist  persist,  stran- 
gulation may  result,  and  another  source  of  pain  may  arise  in  the 
escape  of  the  fluid  from  the  engorged  cyst.  However,  pain  Avill 
not  immediately  be  felt  unless  the  contents  of  the  cyst  are  such 
that  they  irritate  the  parietal  peritoneum,  though  they  may  be 
such  that  a  non-infectious  irritative  peritonitis  may  ensue,  and 
pain  may  arise  from  this  source. 

Pain  may  also  be  associated  with  acute  swelling  and  sudden 
enlargement  of  the  cyst,  such  as  occur  at  the  time  of  great  pelvic 
engorgement,  as,  for  instance,  during  menstruation  or  at  the  time 
of  sexual  connection.  In  some  cases  the  sac  ruptures,  and  blood 
is  thrown  into  the  peritoneal  cavity.  Symptomatically,  it  now 
closely  resembles  ruptured  extrauterine  pregnancy,  from  which  it 
is  hard  to  diagnose  (Winter,  Sampson). 

Adhesions  between  the  cyst  and  other  structures  will  not  cause 
pain  unless  the  adhesions  unite  the  cyst  to  sensitive  structures 
(parietal  peritoneum),  and  conditions  arise  which  cause  traction 
on  the  same. 

The  presence  of  abdominal  or  pelvic  pain  in  patients  with 
ovarian  cysts  usually  indicates  either  secondary  changes  in  the 
cysts,  involving  some  sensitive  nearby  structure,  or  the  presence  of 
some  other  condition,  independent  of  the  cyst,  which  may  cause 
pain.     Previous  symptoms  may  aid  in  the  diagnosis. 

Therefore,  the  principal  causes  of  pain  arising  from  ovarian 
cysts  are  traction  or  twisting  of  the  pedicles  and  the  traction  on 
the  parietal  peritoneum  by  adhesions  (Sampson). 

New  growths  of  the  ovary  as  a  rule  are  not  painful.     Out  of 


THE   VAGINA  755 

an  enormous  experience  Mr.  Doran  could  only  find  sixteen  which 
were  painful  and  of  those  two  were  due  to  adhesions.  New 
growths  are  divided  into  two  classes:  (1)  benign  and  (2)  malig- 
nant. The  benign  growths  are  painful  when  they  interfere  with 
the  ovarian  functions  or  when  they  reach  such  a  size  that  they 
stretch  the  anterior  abdominal  wall  (Donald  and  Lickley,  p. 
430).  Likewise,  in  the  earlier  stages,  from  the  same  cause,  the 
malignant  growths  are  painful;  while  in  the  later  stages  pain  is 
also  caused  by  infiltration  of  the  nerve  fibers  by  the  tumor  cells, 
or  by  the  action  of  the  toxins  of  the  malignant  process  upon  the 
incorporated  terminal  sensory  filaments.  In  some  cases  torsion 
of  the  pedicle  of  the  ovarian  tumor  occurs  and  pain  is  severe.  It 
is  due  both  to  congestion  and  enlargement  of  the  ovary  from  the 
obstruction  to  the  blood  flow,  and  to  the  injury  to  the  nerves  in 
the  pedicle.  In  every  case  it  must  not  be  forgotten  that  malig- 
nant growths  may  be  present  and  not  cause  the  least  pain 
(Brothers). 

THE  VAGINA 

Nerve  Supply. — Pain  is  a  common  indication  of  vaginal  dis- 
orders ;  yet,  because  of  the  easily  accessible  location  of  the  vagina, 
other  and  better  methods  of  diagnosis  than  pain  syndromes  are 
available.  The  vagina  is  supplied  by  sympathetic  and  cerebro- 
spinal nerves.  The  sympathetic  fibers  are  derived  from  the  in- 
ferior hypogastric,  while  the  cerebrospinal  are  derived  from  the 
third  and  fourth  sacral  nerves.  The  reference  pain  seems  to  be  in 
the  fourth  sacral  area.  The  sympathetic  fibers  are  supplied  to  the 
upper  end  of  the  vagina,  which  is  comparatively  insensitive,  while 
the  lower  portion,  which  is  quite  sensitive  to  irritation  of  every 
description,  is'  supplied  by  the  cerebrospinal,  through  the  pudic, 
which  is  derived  from  the  third  and  fourth  sacral. 

Affections  Causing  Pain.- — Pain  produced  by  palpation  of  the 
vagina  should  always  lead  to  inspection,  as  it  may  be  due  to  col- 
poritis.  This  is  indicated  by  the  reddened  and  inflamed  appear- 
ance of  the  mucous  membrane.    A  profuse  discharge  is  also  pres- 


756  PAIN   IN   THE   FEMALE   GENITALIA 

ent-     In  inflammation  the  joain  is  of  a  burning  type.     Tenderness 
of  the  vaginal  wall  and  the  pelvic  floor  is  marked. 

Hemorrhage  into  the  soft  parts  surrounding  the  vagina  is,  as 
a  rule,  j)ainful.  Even  during  the  pains  of  labor,  as  Reed  says, 
the  patient's  attention  is  immediately  attracted,  when  this  compli- 
cation occurs,  by  the  increased  pains  which  are  then  produced. 
On  the  contrary,  chronic  edema  or  hemorrhagic  infiltration  of 
the  vagina  or  vulva  is  entirely  free  of  pain. 

A  small  nodule  on  the  vagina  may  be  a  neuroma  or  a  poly- 
poid growth  of  the  urinary  meatus.  Both  are  very  painful.  Tu- 
herculous  disease  of  the  vidua  is  at  first  not  painful,  but  later  it 
may  cause  considerable  pain.  Cancer  of  the  vulva  is  nearly  al- 
ways very  painful.  Fortunately,  the  disease  is  very  rare.  Cysts 
of  the  vidva,  unless  inflamed,  cause  no  pain.  Cancer  of  the  vagina, 
is  generally  free  from  pain  until  late  in  the  disease. 

Pain  on  urination  and  on  coitus  generally  means  an  inflamma- 
tion of  the  lower  genital  tract  or  a  cystitis.  This  inflammation  is 
frequently  gonorrheal,  but  may  be  the  result  of  trauma.  Every 
case  of  pain  in  the  lower  genital  tract,  associated  with  a  copious 
discharge,  should  be  examined  for  gonorrhea.  If  the  affection  is 
gonorrheal,  as  a  rule,  the  vulvovaginal  gland  (Bartholin's)  is  in- 
volved. The  onset  of  this  complication  is  indicated  by  sudden 
acute  pain  localized  to  the  region  of  the  gland.  Examination  dis- 
closes the  enlarged  and  inflamed  gland. 

A  marked  pain  on  urination  may  indicate  a  vaginal  (anterior 
wall)  tuberculosis.  A  slight  fissure  at  the  urethrovaginal  juncture 
is  also  a  cause  of  severe  pain. 

Sexual  Connection. — When  pain  is  present  during  sexual  con- 
nection, the  female  is  the  one  who  most  frequently  complains, 
except  possibly  in  some  cases  of  disproportion  of  the  parts,  when 
both  the  male  and  the  female  are  pained,  though  the  female  suf- 
fers much  more  than  does  the  male.  Especially  is  this  so  in  the 
period  following  the  first  intercourse.  To  the  female,  the  first 
intercourse  is  almost  invariably  painful,  and  at  this  time  the  male 
should  exercise  the  greatest  moderation.  After  a  short  time,  this 
pain  during  intercourse  wears  away,  unless  the  partners  are  ill- 


m 

« 

H 
P 

m 

Patients     are     extremely 
neurasthenic  and  nervous; 
generally    occurs  in    those 
who  work  very  hard  or  who 
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75S  PAIN   IN   THE   FEMALE   GENITALIA 

mated ;  then  the  aversion  of  the  female  to  the  male  may  hinder 
the  development  of  the  normal  libido  so  that  the  vagina  instead  of 
being  moist  and  well  lubricated  during  intercourse  will  be  dry  and 
rough.  Under  these  circumstances  the  friction  which  ordinarily 
is  productive  of  so  much  pleasure,  inversely  is  productive  of  as 
much  distress.  This  is  only  a  temporary  impediment,  however, 
and,  under  propitious  circumstances,  entirely  disappears.  It  is 
only  when  it  persists  longer  than  a  reasonable  length  of  time,  for 
instance,  a  few  months  after  the  first  intercourse,  that  it  should 
become  a  subject  of  medical  inquiry. 

How  much  the  future  happiness  of  the  husband  and  wife  may 
depend  on  the  cure  of  this  abnormality  can  be  judged  when  it  is 
borne  in  mind  that  no  true  conjugal  bliss  can  be  experienced  so 
long  as  natural  and  pleasurable  intercourse  is  denied.  Many  men 
spoil  their  entire  married  life  by  reason  of  stupidity  and  lack  of 
ordinary  common  sense  in  the  act  of  coitus.  ISTo  two  women  are 
entirely  alike  and  each  should  be  treated  differently  and  be  made 
the  subject  of  careful  medical  study  if  difficulties  due  to  painful 
intercourse  arise  during  married  life.  In  the  majority  of  cases 
the  female  patient  generally  is  the  first  to  complain  and  to  seek 
medical  advice,  because,  as  a  rule,  she  is  the  one  who  suffers  most. 
She  should  be  closely  questioned  as  to  the  time  of  the  pain,  as  to 
whether  it  occurs  before,  during,  or  after  intercourse,  and  she 
should  also  be  asked  to  define  the  positions  in  which  intercourse  is 
most  painful. 

Pain  at  the  beginning  of  intercourse  generally  indicates  a  lack 
of  lubrication  of  the  vaginal  canal,  and  this,  since  it  is  functional, 
is  generally  due  to  an  absence  of  sexual  desire  on  the  part  of  the 
female,  or  a  fear  of  the  results  of  a  coitus  even  though  the  desire 
be  present.  These  women  are  the  ones  who  are  unable  to  experi- 
ence more  than  a  single  coitus  a  night  without  suffering  greatly 
for  it.  They  generally  complain  of  a  burning  pain  during  the 
early  stages  of  the  act,  which  disappears  under  the  excitement  of 
the  libido  to  reappear  in  many  cases  after  the  conclusion  of  the  act. 
Generally,  the  pain  disappears  almost  entirely  in  a  very  short 
time,  but  often  may  persist  to  such  a  degi'ee  that  the  female  will 


THE   VAGINA  759 

not  again,  for  some  time,  permit  the  approach  of  the  male.  Should 
pain  occur  during  the  act,  it  indicates  some  abnormality  or  patho- 
logical condition  of  the  female  parts ;  inflammation  or  ulceration  of 
vaginal  mucosa.  Inspection  will  reveal  this.  It  also  may  indi- 
cate pus  tubes,  oophoritis,  or  appendicitis.  In  these  cases  pain  is 
present  during  the  whole  of  the  act  and  remains  for  some  time 
after.  It  is  also  present  on  particularly  forcible  and  violent 
movements,  which  the  woman  is  very  averse  to  making.  When 
pain  occurs  at  the  end  of  the  act,  after  the  orgasm  has  taken  place, 
it  indicates  some  trouble  with  the  uterine  glands.  Such  a  period 
of  j)ain  is  very  unusual.  Perimetric  adhesions  also  cause  pain, 
which  is  more  marked  toward  the  end  of  the  act. 

In  some  women,  by  whom  pain  is  complained  of  in  the  vagina 
during  the  sexual  act,  digital  examination  reveals  only  a  painful 
spot  at  some  point  in  the  vagina.  No  pathological  lesion  can  bo 
found. 

The  pain  of  the  male  arising  during  sexual  intercourse  is 
slightly  diiferent  in  its  manner  of  production  from  that  of  the 
female.  The  periods  of  pain  likewise  may  be  divided  into:  (1) 
the  pain  j)rior  to  connection;  (2)  the  pain  during  connection,  and 
(3)  the  pain  following  connection. 

Pain  before  connection  is  due  to  some  pathological  lesion  in- 
hibiting erection  of  the  penis,  the  most  common  being  inflamma- 
tion of  the  urethra  (frequently  gonorrheal). 

Pain  during  connection  is  due  to  herpes  of  the  glands,  ulcera- 
tion of  the  glans  penis,  fissure  at  the  meatus,  inflammation  of  the 
glans  or  foreskin,'  adherent  prepuce,  or  an  inflamed  frenum. 

Pain  at  the  time  of  the  orgasm  and  persisting  for  some  time 
afterward  is  due  to  prostatitis  or  posterior  urethritis.  In  any 
case,  when  pain  during  intercourse  is  complained  of,  all  possible 
lesions  in  both  the  male  and  the  female  should  be  thoroughly  in- 
vestigated before  forming  a  decision. 


CHAPTEK  XXXIII 


PAIN  IN  THE  CHEST 


When  a  patient  has  a  pain  in  the  chest,  the  idea  first  sug- 
gested to  himself,  as  well  as  to  most  physicians,  is  that  he  is  suf- 
fering from  some  lesion  of  the  heart  or  of  the  lungs — of  the  heart, 
if  the  pain  is  in  the  left  half  of  the  thorax;  of  the  lungs,  should 
the  pain  be  in  any  other  part  of  the  chest.  While  in  many  cases 
this  is  true,  in  many  others  it  is  not ;  and,  unfortunately  for  the 
careless  physician,  the  exceptions  far  outnumber  the  rule.  Pains 
in  the  chest  are  the  result  of  many  causes. 

In  the  first  place,  they  may  be  due  to  injuries  or  disease  located 
in  any  one  of  the  structures  composing  the  chest  walls;  or  they 
may  be  felt  in  the  walls  and  be  produced  elsewhere,  as  is  seen  in 
referred,  reflected,  and  transferred  pains. 

THE  THORACIC  WALLS 

The  structures  composing  the  thoracic  wall  are:  (1)  the  skin, 

(2)  muscle,  fascia,  and  nerves,  (3)  bone,  and  (4)  pleura  and  sub- 

pleural  tissues. 

THE    SKIN 

The  skin  of  the  thorax  is  painful  in  all  those  lesions  which 
cause  epidermic  pain,  such  as  neuralgia,  hysteria,  inflammation, 
hyperesthesia  and  hyperalgesia  from  reflex  causes. 

Neuralgia. — Neuralgia  produces  a  very  tender  skin,  so  that  the 
slightest  touch  is  painful.  It  is  a  frequent  accompaniment  of 
influenza  or  some  of  the  acute  infectious  diseases.  When  found, 
inquiries  should  be  made  in  regard  to  the  presence  of  any  recent 
illness.  A  characteristic  of  neuralgic  pain  is  that  it  moves  around 
freely  from  place  to  place,  and  does  not  stay  very  long  in  any 
one  location.  It  is  also  present  in  other  parts  of  the  body,  and 
760 


THE    THORACIC    WALLS 


761 


the  subjacent  muscnlar  tissues  are,  as  a  rule,  very  sensitive  to 
pinching  or  squeezing. 

Hysteria. — In  hysteria  the  skin  is  tender  only  in  certain 
areas. 

These  areas  in  the  same  person  are  constant  in  location,  and 
generally  are  produced  only  by  certain  types  of  irritants.  In  some 
these  areas  may  be  sensitive  to  pinching  and  entirely  insensitive  to 


Fig.  173. — Areas  of  Cutaneous  Distribution  op  the  Thoracic  Seg- 
ments.    (Head,  Brain,  Vol.  XVI,  p.  130.) 
The  1st,  2d  and  3d  thoracic  areas  are  the  ones  mostly  affected  in  cardiac 
disease.     The  4th  thoracic  is  the  one  especially  involved  in  lung  disease. 

pin-point  pressure;  while  in  others  these  sense  perceptions  may 
be  reversed. 

Inflammation. — Inflammation  of  the  skin  of  the  thorax  is  un- 
common, except  when  local  irritation,  particularly  in  the  form  of 
a  mustard  plaster,  etc.,  has  been  applied. 

Hyperesthesia  and  Hyperalgesia. — Hyperesthesia  and  hyper- 
algesia are  the  result  of  nerve  irritation,  either  in  adjacent  or  in 
distant  areas.  The  adjacent  causes  may  be  inflammation  of  any 
of  the  sublying  organs,  such  as  osteomyelitis  of  the  ribs,  myositis 
of  the  chest  muscles,  or  a  communicated  inflammation  from  the 
pleura.  In  all  cases  where  pain  is  complained  of  in  the  chest 
these  conditions  should  be  carefully  sought.  Symptoms  leading 
to  the  diagnosis  of  inflammation  are  swelling,  local  edema  and 


762  PAIN    IN    THE    CHEST 

restriction  of  the  respiratory  movement  on  the  affected  side.  In 
addition  to  local  causes,  hyperalgesia  may  also  be  produced  reflexly 
by  lesions  of  the  heart  and  lungs.  The  segmental  areas  of  these 
hjperalgesic  zones  are  given,  according  to  Head,  in  Fig.  173. 

MUSCLE^  FASCIA  AND  NERVES 

Muscle  Pain  — If  there  are  no  definite  zone  areas  of  hyper- 
algesia and  hyperesthesia  and  the  areas  of  sensitiveness  corre- 
spond fairly  well  to  the  limitations  of  the  different  chest  muscles, 
myositis  is  very  likely  present.  When  it  is,  pain  is  produced  by 
grasping  the  muscle  between  the  fingers  and  pinching  it,  or  else 
by  trying  to  raise  it  from  its  bed.  If  the  muscle  is  hypersensi- 
tive, pain  results.  Also,  pain  is  produced  on  breathing  by  move- 
ment of  the  affected  muscle,  while  rest  gives  relief.  If  the  inter- 
costal muscles  are  affected,  sudden  pressure  in  the  intercostal 
spaces  causes  pain,  and  breathing  is  inhibited  on  the  affected  side. 
If  myositis  be  present  light  pressure  applied  to  the  muscle  is 
grateful,  and  severe  pressure  is  painful.  Also  the  pain  does  not 
radiate.  In  neuralgia,  on  the  contrary,  pressure  of  all  kinds  is 
most  painful  and  radiation  is  usual. 

Fascial  Pain. — Musser  speaks  of  a  chronic  inflammation  of 
the  fibrous  attachments  of  the  muscles  as  being  one  of  the  causes 
of  chest  pain.  This  pain  is  increased  by  motion,  and  persists  for 
long  periods. 

NEEVE    AND    MUSCLE    PAIN 

Nerve  Pain. — If  pain  is  present  in  the  intercostal  spaces, 
either  the  nerve  or  the  muscle  is  involved.  The  nerve  may  be 
affected  either  with  neuritis  or  neuralgia. 

Neuritis. — When  the  pain  is  due  to  neuritis,  it  is  referred 
along  the  interspaces  and  the  breathing  is  very  much  restricted. 
The  pain  is  also  produced  by  pressure  made  in  the  interspace 
about  two  inches  from  the  vertebra,  and  when  so  produced  runs 
out  anteriorly  over  the  distribution  area  of  the  intercostal  nerves. 
A  good  way  to  determine  the  presence  of  nerve  inflammation  is 
to  run  the  finger  round  from  the  back  to  the  front,  in  the  inter- 


THE   THORACIC   WALLS 


763 


costal  space,  making,  at  the  same  time,  considerable  pressure.     If 
neuritis  is  present,  the  pain  is  severe. 

A  somewhat  similar  condition  is  the  nerve  pain  due  to  herpes 
zoster.  In  this  pain  is  very  severe  over  an  intercostal  nerve. 
Tenderness,  also,  is  excessive.     In  a  day  or  two  small  vesicles 


C,     Intercostal 
nerve  XII 


D,    M.   transv. 
abdom. 


E,  Iliohypogas- 
tric nerve 


F,  Lateral 
branch  inter- 
costal nerve 
XII 


G,  Ramus  cu- 
taneous later- 
al, iliohypo- 
gastric nerve 


H,  1 1  i  o-i  n  g  u  i- 
nalis  nerve 


Fig.  174. — Points  At  Which  The  Inter- 
costal Nerves  Become  Superficial. 
Especially  the  11th  and  12th  over  the 
iliac  region,  which  is  the  location  of  the 
referred  pain  in  pneumonia  and  dia- 
phragmatic pleurisy  of  the  right  side. 
(Splateholz,  Leipzig,  1909,  vol.  3,  740.) 


I,   Sheath   rect. 
abdom. 


J,   Umbilicus 


K,    M .   rect. 
abdom. 


L,     M.    obliqu. 
int.   abdom. 


M,  Rami  cuta- 
nei  ant.  inter- 
costal nerve 
XII 


N,    A  n  nul  us 
inguinalis 


O,    Funiculus 
spermaticus 


make  their  appearance  over  the  site  of  the  pain.     Herpes  then  be- 
comes apparent. 

Neuralgia. — True  intercostal  neuralgia,  like  all  neuralgias, 
may  arise  without  any  obvious  cause.  The  fifth  to  the  ninth 
thoracic  nerves  are  the  ones  generally  involved.  The  pain,  owing 
to  the  anatomical  relation  of  the  parts,  is  worse  on  breathing,  or 
on  any  movement  of  the  chest  wherein  stretching  of  the  nerve 
(pressure  irritation)  may  occur.  This  pain  must  not  be  mistaken 
for  pleurisy.  The  absence  of  the  pleural  friction  rub  is  evidence 
of  value  against  its  pleural  origin.  The  reason  for  this  confusion 
is  clear  when  it  is  stated  that  the  thoracic  nerves  divide  into  two 
branches,  the  external  and  the  internal.     The  internal  supply  the 


764  PAIN    IN    THE    CHEST 

pleura,  and  the  external  supply  the  anterior  body  wall,  so  that, 
should  the  pleural  branches  be  affected,  the  stimulus  may  be  trans- 
ferred to  the  external  branch  and  neuralgic-pleural  pain  may  re- 
sult. On  the  other  hand,  when  the  first  two  dorsal  nerves  are 
affected,  the  pain  may  run  down  the  inner  side  of  the  arm 
through  the  intercostal-humeral  nerve.  Intercostal  neuralgia  may 
arise  from  thickening  of  the  spinal  meninges,  specific  or  tubercu- 
lous meningitis,  or  from  new  growths,  osseous  or  otherwise.  It 
may  also  arise  from  intravertebral  pressure,  diabetes,  or  other 
general  conditions  causing  neuralgia.  An  intercostal  neuralgia 
may  be  the  early  sign  of  a  tabes  or  of  a  spinal  cord  tumor. 

BONE   PAIN 

Bone  Disease. — Bone  diseases  (osteomyelitis)  produce  pain, 
soreness,  and  redness  over  the  area  under  which  lies  the  necrosing 
bone  tissue.  In  these  cases  the  location  of  the  swelling  and  the 
signs  of  inflammation  render  a  diagnosis  easy.  Elevation  of  tem- 
perature and  an  increase  in  the  pulse  rate  also  aid  in  the  diag- 
nosis. 

Fractures. — Where  a  rib  is  fractured,  the  pain,  on  breathing, 
is  very  severe.  Generally,  the  inspiratory  act  commences  all  right, 
but,  because  of  pain,  is  brought  to  a  sudden  stop.  On  palpation, 
crepitus  and  abnormal  mobility  of  the  rib  can  be  felt.  A  diagnos- 
tic sign  of  value  is  pain  over  the  location  of  the  fracture  when 
pressure  is  made  between  two  hands,  one  placed  on  the  anterior 
chest  wall  and  the  other  on  the  back. 

PiiEUKAL  Pain 
See  p.  769. 

REFERRED  AND  REFLECTED  PAINS  OF  THE  THORACIC 

WALLS 

Referred  and  reflected  hyperalgesia  have  been  mentioned  as 
causes  of  chest  j^ain.  These  are  generally  accompanied  by  subjec- 
tive pain.  There  may  also  be  a  subjective  pain  without  hyper- 
algesia. This  pain  is  referred  from  distant  lesions,  such,  for  in- 
stance, as  pain  in  the  shoulder,  in  diseases  of  the  gall  bladder, 


REFERRED    AND    REFLECTED    PAINS 


765 


or  posterior  thoracic  pain  in  lesions  of  the  stomach.  Both  of  these 
are  transferred  pains,  the  same  as  the  pain  which  is  present  in 
the  chest  wall  over  the  cardiac  area  in  some  cases  of  heart  disease. 
All  these  pains  depend  for  their  production  upon  the  transference 
of  stimuli  from  the  sympathetic,  through  the  cells  in  the  cord,  to 
the  nerves  supplying  the  body  wall.     In  some  cases,  this  reflection 


A,     Tenderness 
in   aortitis 


B,  Liver  disease 

Gall-bladder 
disease 

Extra-uterine 

pregnancy 

ruptured 


C,  Pain  in  inter- 
costal spaces: 

1,  Intercostal 
neuralgia 

2,  Referred 
pain  (spinal 
caries) 

3,  Intercostal 
myalgia 


D,  Tenderness 
due  to  trac- 
tion  from 
coughing 


E,  Gall-bladder 
disease 


F,  Tenderness 
in  liver  dis- 
ease 


Fig.  175. — Location  of  Tenderness  in 
Various  Diseases  of  the  Chest 
AND  Abdomen. 


G,  Cardiac  dis- 
orders 


H,  Subacro- 
mial bursal 
inflammation 


I,  Tenderness  in 
angina  pec- 
toris 


J,  Bronchitis 

Necrosis  of 
the  sternum 

Mediastinitis 
or  medias- 
tinal  sarcoma 
Aneurysm 
Hyperchlor- 
hydria 
K,  Gastric  ulcer 


L,    Disease     of 
the  spleen 


M,   Disease     of 
the  cecum 


passes  entirely  across  the  cord,  and  the  pain  is  felt  on  the  side 
opposite  to  that  of  the  lesion.  It  also  may  be  transferred  to  a 
higher  or  lower  level  of  the  cord  and  be  felt  at  a  higher  or  lower 
level  of  the  body. 

These  transferred  pains,  when  present  in  the  chest,  often 
cause  mistakes  in  diagnosis,  since  they  are  likely  to  cause  confu- 
sion as  to  which  is  the  side  of  the  lesion.  They  may  also  attract 
attention  from  a  distant  causative  pathology,  as  is  sometimes  seen 


766  PAIN    IN    THE    CHEST 

in  appendicitis,  when  pneumonia  or  pleurisy  is  diagnosed  witli  an 
entire  disregard  of  the  appendiceal  condition.  However,  the 
diagnosis  is  not  always  wrong,  for  in  some  cases  there  may  be 
local  conditions  (congestion,  etc.)  in  the  lungs  to  account  for  the 
chest  pain  associated  with  appendicitis,  as  is  emphasized  by  J.  B. 
Roberts  (^76).  In  other  cases  the  pain  may  be  felt  in  the  ap- 
pendix area  when  the  lesion  is  in  the  lung.  This  pain  may  be 
due  to  irritation  from  a  diaphragmatic  pleurisy  associated  with 
the  pneumonia,  the  stimulus  being  carried  through  the  eleventh 
and  twelftli  intercostal  nerves.  The  j^ain,  as  is  usual,  would  then 
be  felt  at  the  point  where  the  eleventh  and  twelfth  nerves  become 
superficial,  that  is,  in  the  right  lower  quadrant  of  the  abdomen. 

Transferred  and  reflected  pains,  in  distention  of  the  stomach 
and  colon,  are  found  on  the  lateral  surface  of  the  chest,  follow- 
ing ihe  points  of  attachment  of  the  diaphragm.  These  pains  occur 
in  the  two  conditions  in  which  the  greatest  traction  on  the  dia- 
phragm is  present,  namely: 

(1)  In  states  of  gi'eat  cardiac  and  respiratory  activity.  The 
heart  and  lungs,  which  in  a  normal  person,  under  abnormal  con- 
ditionfe  of  exertion,  would  be  incited  to  great  effort,  would,  in  a 
patient  who  is  emphysematous,  be  incited  to  much  greater  effort, 
owing  to  the  difficult  circulation  of  blood  through  the  lungs.  This 
relatively  greater  increase  of  cardiac  and  respiratory  activity 
would  produce  much  greater  than  normal  traction  on  the  dia- 
phragm, and  this,  in  turn,  would  be  communicated  to  the  chest 
wall  at  the  points  of  diaphragmatic  attachment.  Thus  it  is  that 
after  violent  exercise  pain  is  so  frequently  produced  at  these 
points  of  attachment. 

(2)  In  enlargement  and  dilatation  of  the  stomach  it  is  also 
common  to  find  pain  or  a  sense  of  traction  along  the  line  of  attach- 
ment of  ihe  diaphragm  to  the  chest  walL  This  pain  is  the  result 
of  the  diaphragmatic  pull. 

Distention  of  the  stomach  and  intestine  frequently  causes  such 
a  sudden  and  severe  pain  in  the  cardiac  region  that  it  is  confused 
with  angina  pectoris;  but  a  hurried  examination  of  the  epigas- 
trium will  disclose  the  enlarged  and  tympanic  stomach  and  quickly 


REFERRED    AND    REFLECTED    PAINS  767 

clarify  the  diagnosis.  The  distended  large  intestine,  also,  at  times 
produces  the  same  symptoms.  Symptomatic  of  the  latter  condi- 
tion is  a  painful  spot  on  the  left  side  of  the  chest  at  the  margin  of 
the  ribs  (in  men  at  a  point  opposite  the  suspender  button).  In 
women  the  presence  of  this  pain  frequently  causes  them  to  loosen 
the  corsets  (Reynier,  231). 

According  to  Brown  (Osier's  "System"),  pain  over  the  front 
of  the  chest  is,  as  a  rule,  a  referred  pain  from  a  diseased  lung, 
though  it  may  also  be  due  to  an  acute  pleurisy  or  to  the  traction 
of  pleural  adhesions.  According  to  the  same  author,  pain  over 
the  lower  part  of  the  thorax  may  be  due  to  pleurisy,  while,  if  it  is 
over  the  interscapular  region  it  is,  as  a  rule,  referred,  and  is  the 
result  either  of  a  pleurisy  or  of  jiressure  on  the  intercostal  ner\'es 
from  enlarged  mediastinal  glands. 

Pain  radiating  around  the  chest  wall  is  also  present  in  herpes 
zoster  and  tabes  dorsalis,  as  well  as  in  vertebral  caries,  if  the 
intercostal  nerves  are  involved.  Mediastinal  glandular  involve- 
ment at  times  produces  a  pain  in  front  of  the  chest,  beneath  the 
sternum,  and  at  other  times  in  the  back,  underneath  the  vertebrae. 
Should  pain  be  present  in  the  back  between  the  scapulse,  the  fol- 
lowing should  be  sought :  vertebral  disease,  limg  disease,  particu- 
larly tuberculosis  (here  the  pain  is  more  of  an  aching),  aortic  dis- 
ease (aneurysm),  j^leural  disease  (pleuritic  adhesions),  splenic 
and  gastric  lesions  (inflammation  and  over-distention).  Should 
pain  be  present  at  the  angle  of  the  scapula  on  the  right  side,  it 
indicates  liver  involvement;  if  at  the  angle  of  the  scapula  on  the 
left  side,  it  indicates  splenic  involvement. 

Localization  of  Pain  on  the  Chest  Wall. — Pain  on  the  lateral 
wall  of  the  thorax  may  be  due  to  pleurisy,  intercostal  neuralgia, 
or  pleurodynia.  Upon  the  upper  surface  of  the  thorax,  in  the 
region  of  the  shoulder,  pain  may  be  due  to  pericarditis  (left 
shoulder)  (McKenzie),  peritonitis,  pleurisy,  hepatic  abscess 
(right  shoulder),  or  colic.  According  to  Monro  (32),  Schmidt, 
and  others,  the  pain  referred  to  this  area  is  propagated  through 
the  phrenic  nerve  to  the  fourth  cervical  (sometimes,  also,  to  the 
fourth  and  fifth),  and  thence  through  the  external  supraclavicular 


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PAINS    WITHIN    THE    THORAX  769 

nerve  (derived  from  the  third  and  fourth  cervical  nerves)  to  the 
integument  over  the  shoulder  tip. 

Pains  above  the  shoulder  are  due  to  involvement  of  the  supra- 
acromial  nerves,  branches  of  the  fourth  cervical.  Deep-seated 
pains,  referred  to  the  parts  over  the  shoulder  joint,  and  in  the 
deltoid,  lie  in  the  distribution  area  of  the  circumflex  nerve,  which 
originates  from  the  fourth,  fifth,  and  sixth  cervical  nerves.  When 
the  pains  are  behind  the  shoulder  and  over  the  deltoid,  thej  are 
also  due  to  involvement  of  the  circumflex,  and  at  the  point  where 
the  nerve  becomes  superficial  a  painful  spot  is  present  (Dana, 
123b).  Tenderness  is  present  over  the  eleventh  and  twelfth 
dorsal  and  the  first  and  second  lumbar  vertebral  spines  in  gastric 
lesions.  (For  other  points  of  tenderness  in  gastric  lesions,  see 
under  Stomach.) 

PAINS  WITHIN  THE  THORAX 

Inside  the  thorax  are  the  following,  all  of  which  have  the 
power,  directly  or  indirectly,  of  causing  pain:  (1)  the  pleura,  (2) 
the  heart,  (3)  the  lungs,  (4)  the  mediastinal  glands,  (5)  the  esoph- 
agus, and  (6)  the  nerves  and  vessels  passing  through  the  thorax. 

In  diseases  of  the  heart  and  lungs  hyj)eralgesia  may  be  present 
in  the  area  of  the  first  six  dorsal  visceral  segments.  Sometimes 
it  is  felt  as  high  as  the  seventh  or  eighth  cervical  or  as  low  as  the 
seventh  or  eighth  dorsal  (Head).  Generally,  though,  in  the  case 
of  the  heart,  the  hyperalgesia  is  limited  to  the  upper  four  dorsal, 
while  that  of  the  lungs  is  comprised  within  the  upper  six  dorsal. 
The  areas  of  distribution  of  these  segments  are  illustrated  in 
Fig.  173. 

THE    PLEUEA 

Innervation. — The  parietal  pleura  is  iimer\''ated  by  the  inter- 
costal, sympathetic,  and  vagus  nerves.  The  visceral  pleura  is 
innervated  by  the  vagus  and  sympathetic.  The  pericardial  pleura 
sends  its  sensory  stimuli  through  the  vagus  and  possibly  through 
the    phrenic.     The    diaphragmatic    pleura    sends    impulses    over 


770  PAIN    IN    THE    CHEST 

the  phrenic  and  also  in  jiart  through  the  last  six  intercostal 
nerves. 

In  iileurisj  pain  is  a  symptom  of  gTeat  diagnostic  value,  be- 
cause it  is  almost  invariably  present.^  The  method  of  its  pro- 
duction and  its  areas  of  distribution  have  been  discussed  in  the 
preceding  j^ages.  In  some  cases  the  cutaneous  liy23eralgesia  may 
be  on  the  opposite  side  of  the  body  to  the  one  aifected ;  but  the 
deep  tenderness  is  always  on  the  affected  side,  and  this  is  a  point 
to  be  remembered,  for  it  may  be  most  useful  in  a  differential  diag- 
nosis. Percussion  is  a  good  method  of  defining  this  deep  tender- 
ness. On  palpating  or  percussing  those  cases  of  pleurisy  in  which 
pain  is  complained  of  over  the  abdomen  as  far  as  the  umbilicus, 
it  is  noticed  that  tenderness  is  not  present  on  percussion  and  pal- 
pation beyond  the  costal  margins,  and  this  is  a  sign  of  the  utmost 
value  in  the  making  of  a  diagnosis.  When  tenderness  to  deep 
pressure  or  percussion  is  present,  it  is  a  fair  indication  that  the 
diseased  process  lies  in  the  percussed  area. 

The  mere  fact  that  an  area  painful  to  palpation  or  percussion 
is  present  does  not  necessarily  prove  a  pleural  involvement,  for 
these  pain  areas  may  be  due  to  other  causes  than  a  pleurisy ;  like- 
wise their  absence  is  of  no  negative  value,  for  a  pleurisy  may  be 
present  and  run  a  painless  course.  A  method  of  arriving  at  a 
diagnostic  conclusion  as  to  whether  the  pain  felt  in  the  chest  wall 
is  or  is  not  due  to  pleural  involvement  is  to  inhibit  the  respira- 
tions on  the  affected  side,  as  by  strapping.  This  will  at  once  stop 
the  pain,  if  it  be  due  to  a  pleurisy.  On  the  right  side,  if  the  pain 
is  the  result  of  perihepatitis,  strapping  will  aggravate  it.  In  dia- 
phragmatic pleurisy  respiration  is  painful,  but  not  nearly  so 
much  so  as  it  is  in  pleurisy  of  the  lateral  wall.  In  many  cases 
of  diaphragmatic  pleurisy  the  pain  is  referred  to  the  chest  and 
abdominal  wall,  in  the  distribution  area  of  the  tenth,  eleventh, 
and  twelfth  thoracic  nerves. 

The  pleura  also  is  probably  connected  with  the  seventh,  eighth, 

1  According  to  Dr.  Lord,  89.70  per  cent,  of  all  cases  of  serofibrinous 
pleurisy  give  rise  to  pain  at  least  sometime  in  their  course. 


PAINS   WITHIN   THE   THORAX  771 

and  ninth  visceral  dorsal  segments,  so  that  the  pain,  when  reflected, 
is  felt  in  these  segmental  zones,  most  commonly  on  the  right  side 
(Head.  See  Fig.  173).  This  corresponds  closely  with  the  state- 
ments of  Huss  (102),  who  says  that,  in  pleuritis,  irrespective  of 
the  area  in  which  the  disease  is  present,  the  pain  occurs  princi- 
pally in  the  region  of  the  mammillary  line,  between  the  fifth 
and  eighth  ribs.  When  the  inflammation  lies  in  the  outer  and 
lower  half  of  the  pleura,  the  pain  may  be  felt  in  the  region  of 
the  hypochoudrium,  in  the  region  of  the  quadratus  lumborum, 
and  in  the  epigastrium   (though  infrequent). 

In  all  cases  in  which  the  parietal  pleura  is  involved  (and  it 
is  involved  in  nearly  all  pleuritic  processes  of  whatever  origin) 
pain  due  to  irritation  of  the  intercostal  nerves  is  also  felt,  and  is 
localized  to  the  diseased  area.  If  the  pleurisy  should  extend  and 
involve  the  mediastinum  there  is  then  produced  a  mediastino- 
pericardio-pleuritis.  This  causes  severe  pain  on  breathing.  Per- 
cussion over  the  sternum  is  painful,  and  pressure  in  the  intercostal 
spaces  on  either  side  of  the  sternum  causes  pain.  Reflected  and 
referred  pains  are  absent ;  only  the  direct  pain  is  present. 

Character  of  the  Pain  in  Pleurisy. — The  pain  of  pleurisy  may 
be  slight  or  severe,  depending  upon  the  type  and  the  location  of  the 
pleuritic  involvement.  If  the  visceral  pleura  is  involved,  it  is 
not  as  severe  as  though  the  parietal  pleura  were  afi^ected.  Like- 
wise involvement  of  the  diaphragmatic  pleura,  in  the  absence  of 
deep  inspiration,  may  produce  no  very  severe  pain.  In  all  cases 
pleural  pain  of  whatever  origin  is  generally  provoked  on  deep  in- 
spiration, coughing,  yawning,  singing,  and  laughing.  As  a  rule 
it  is  localized  in  the  areas  of  maximum  tenderness  of  the  seventh 
and  eighth  dorsal  segments  (q.  v.).  If  the  intercostal  nerves  be- 
come affected  and  intercostal  neuritis  results,  the  pain  is  referred 
to  the  anterior  area  of  distribution  of  these  nerves.  Should  the 
pain  suddenly  cease,  it  is  frequently  an  indication  of  a  beginning 
hydrothorax. 

In  those  cases  in  which  the  subjective  pain  is  on  the  opposite 
side  to  the  one  involved  Gerhart   thought  that  the  transference 


772  PAIN    IN    THE    CHEST 

might  be  due  to  a  comnmnication  in  the  anterior  mediastinum,  be- 
tween the  two  sets  of  intercostal  nerves.  In  this  regard,  Huss 
speaks  (102,  p.  245)  of  a  case  in  which  such  a  connection  was 
found  between  the  fourth  and  the  middle  part  of  the  third  nerve 
on  the  right  side  and  the  corresponding  nerve  on  the  left  side. 


CHAPTEK  XXX17 

HEART  DISEASE 

GENERAL    CONSIDERATIONS 

It  has  frequently  been  said  that  cardiac  disease  does  not  cause 
I^ain.  Even  well-known  clinicians  have  claimed  that  the  heart  (of 
itself)  does  not  give  rise  to  painful  sensations.  Thej  attribute 
all  the  pains  which  may  be  present  in  the  chest,  over  the  area  of 
the  heart,  as  not  being  due  to  disease  of  the  heart  itself,  but  as 
the  result  of  other  changes,  such  as  rheumatism  of  the  pectoral 
or  intercostal  muscles,  or  intercostal  neuralgia.  Yet  it  is  not 
always  wise  for  the  clinician  summarily  to  dismiss  a  pain  in  the 
chest  and  rate  it  as  being  due  to  any  one  of  these  conditions, 
especially  so  in  those  who  are  weak  and  debilitated  from  over- 
work or  disease.  In  the  former  class  of  patients  the  pain,  though 
slight,  may  be  the  first  indication  of  a  cardiac  exhaustion.  Early 
and  efficient  remedies  directed  against  this  exhaustion  may  pro- 
long the  patient's  life  for  years,  while  neglect  of  the  warning 
signs  may  pave  the  way  for  his  early  death.  Every  case  of  pain 
or  discomfort,  in  the  areas  usually  associated  with  cardiac  disease, 
should  lead  the  physician  to  question  closely  his  patient  as  to  age, 
habits,  manner  of  work,  and  past  diseases,  and  then  to  make  a 
thorough  examination  of  the  entire  body,  with  special  attention  to 
the  chest.  The  physician  should  also  bear  in  mind  that  the  heart 
may  be  gTeatly  diseased  and  yet  give  no  apparent  sig-n  of  its  dis- 
tress, excepting  in  cases  of  referred  visceral  hyperalgesias.  Should 
these  hyperalgesias  be  present,  they  of  themselves,  even  though  no 
other  signs  of  heart  disease  are  apparent,  are  of  sufficient  value 
to  merit  a  diagnosis  of  cardiac  involvement.  The  absence  of  hv- 
peralgesic  zones  does  not  carry  weight  against,  as  their  presence 
carries  weight  for,  the  existence  of  cardiac  disease. 

773 


774  HEART   DISEASE 

It  was  in  1873  that  Loomis  first  called  attention  to  the  asso- 
ciation of  heart  lesions  with  referred  pains.  For  instance,  in  an 
article  published  in  that  year,  he  says  that  "disturbances  of  the 
cardiac  plexus,  by  reflex  irritation,  produce  pain  in  the  arm,  in 
the  top  of  the  shoulder,  and  the  base  of  the  neck."  However,  it 
was  not  until  Head  and  McKeuzie  published  their  articles  on 
referred  and  reflected  pain  that  a  clear  conception  of  this  rela- 
tionship of  the  pain  to  the  cardiac  disease  was  reached. 

Nerve  Supply  of  the  Heart. — The  cutaneous  hyperalgesia,  in 
a  case  of  heart  disease,  lies  in  the  cutaneous  tissues  which  extend 
from  the  eighth  cervical  to  the  fourth  dorsal  segments,  as  illus- 
trated in  Fig.  176.  In  this  illustration,  it  should  be  noticed  that 
the  eighth  cervical  and  the  first  and  second  dorsal  zones  are  shown 
as  extending  down  the  arm.  This  downward  extension  explains 
why,  in  some  cases,  the  pain  of  cardiac  disease  runs  down  the 
inner  side  of  the  arm,  frequently  as  far  as  the  little  finger.  The 
reason  for  this  downward  extension  is  that,  in  early  embryonic  life, 
the  spinal  nerves  are  distributed  around  the  entire  body ;  but  as  the 
body  develops,  and  the  arms  and  limbs  are  projected  from  its 
surface,  the  nerves  are  dragged  out  with  them,  and  are  carried  by 
developing  tissues  farther  and  farther  away  from  their  point  of 
origin,  until  we  find  them  in  irregular  though  always  concentri- 
cally arranged  zones,  as  in  man.  Ross  explains  how,  in  some 
cases,  the  areas  supplied  by  the  dorsal  segments  are  not  continu- 
ous from  the  chest  to  the  arms,  but  are  broken  by  intervening 
areas ;  for  instance,  the  third  dorsal  is  broken,  the  gap  between  the 
two  portions  being  made  by  the  ingrowing  second  dorsal.  The 
different  segments  of  skin  grow  with  various  degrees  of  rapidity, 
so  that  in  some  cases  the  different  skin  segments  become  sepa- 
rated from  each  other. 

Diagnosis  by  Means  of  Location  of  Referred  Pain ^^The  man- 
ner of  distribution  of  the  cord  zones  explains  how  the  pain  of 
cardiac  diseases  may  be  distributed  down  the  inner  side  of  the 
arm,  and  at  the  same  time  over  the  left  upper  half  of  the  chest. 
It  also  explains  why,  in  some  cases  of  cardiac  lesions,  the  breasts 
are  very  sensitive.     Hyperalgesia  due  to  cardiac  disease  may  first 


GENERAL    CONSIDERATIONS 


775 


appear  only  after  some  severe  and  debilitating  disease,  such  as 
pneumonia,  which  so  sensitizes  the  already  reduced  tissues  that 
the  slightest  stimulus  will  give  rise  to  pain  (in  the  cardiac  areas). 
At  the  same  time  the  hyperalgesic  areas  of  the  debilitating  disease 
will  be  present.  For  example,  if  the  heart  is  affected  (without 
pain)  and  the  patient  catches  pneumonia,  then  the  previously 
non-painful  heart  becomes  very  painful,  and  cutaneous  areas 
of  hyperalgesia  appear.  These  heart  areas  may  persist  for  a 
long  time  after  the  pneumonic  areas  have  disappeared,  and  vice 


Local  tenderness 

Area  of  hyperalgesia 

Points  of  local  ten- 
derness (Hoover)  . 
Tenderness  aortitis 
(Hoover) 

Area  of  hyperal- 
gesia in  heart 
disease 


Fig.  176. — Location  of  Hyperalgesic  Zones  and  the  Areas  of  Pain 

IN  Cardiac  and  Aortic  Lesions. 

In  some  cases  there  is  a  crossed  reference  and  the  pain  is  referred  to  an 

analogous  area  on  the  opposite  (right)  side. 


versa.  In  cardiac  disease  certain  muscles,  such  as  the  pectorales, 
the  intercostals,  the  trapezius,  and  the  sternomastoid,  may  be  very 
sensitive  to  pinching  and  squeezing. 

That  the  pain  felt  in  heart  disease  is  not  local  but  referred 
pain  is  set  forth  in  the  following  arguments: 

(1)  The  heart  is  in  contact  w^ith  the  chest  wall  in  only  a  small 
part  of  its  anterior  surface,  and  the  pain  and  tenderness  associated 
with  the  cardiac  disease  cover  an  area  several  times  this  extent. 

(2)  If  the  pain  were  present  in  the  heart  itself,  movements  of 
the  heart,  such  as  expansion  or  contraction,  would  produce  a  varia- 
tion in  the  pain  and  tenderness.  Such  is  not  the  case.  The  same 
arguments  apply  to  the  origin  of  pain  in  lesions  of  the  lungs. 


"76 


HEART    DISEASE 


Another  point  of  interest,  as  well  as  of  value,  in  diagnosis  of 
heart  lesions  is  that  in  the  first  attack  of  an  inflammatory  affec- 
tion of  the  heart,  say,  in  endocarditis,  the  hyperalgesia  zones  ara 
very  prominent,  increasing  and  receding  with  each  exacerbation 
or  recession  of  the  disease.  After  the  first  attack,  when  the 
process  becomes  chronic,  as  in  chronic  valvular  disease,  the  re- 
ferred zones  of  hyperalgesia  arc,  as  a  rule,  absent.     However,  if 


'V  Area  of  hyperalgesia 


«  The  area  of  h>'per- 
algesia  down  the 
arm  was  not 
wider  thanj^ 
inch,  and  began 
abruptly  below 
the  shoulder,  and 
ended  abruptly 
before  it  reached 
the  elbow 


Fig.  177. — An  Area  of  Hyperalgesia  Corresponding  to  Portions  op 
THE  2d,  3d  and  4th  Dorsal  Zones. 

The  2d  dorsal  is  almost  absent.  The  area  corresponding  to  a  portion  of  the 
4th  dorsal  is  more  than  ordinarily  prominent.  In  this  case  also  there 
was  no  tenderness  to  blunt  pressure,  even  in  the  area  which  was  hyper- 
algesia to  pin-point  pressure.  The  case  was  a  mitral  regurgitation  re- 
covering from  an  acute  attack. 


at  this  time  an  acute  attack  of  endocarditis  should  ensue,  the 
hyperalgesic  areas  may  or  may  not  appear.  The  reason  that  they 
do  not  reappear  is  not  clear,  but  it  probably  is  the  result  of  tli3 
destruction,  in  the  first  attack,  of  the  sensory  terminal  nerve  fila- 
ments in  the  endocardium,  so  that,  during  the  second  and  subse- 
quent attacks,  they  cannot  respond  to  the  irritating  stimuli.  This 
is  well  illustrated  in  the  case  of  Lillian  IT.,  a  school  girl  affected 
with  chorea.  While  under  observation  a  mitral  regurgitation  de- 
veloped, and  at  its  height  gave  rise  to  the  hyperalgesic  areas 
shown  in  Fig.  177. 

As  improvement  occurred  the  zones  gradually  became  less  ex- 


GENERAL    CONSIDERATIONS 


777 


tensive,  first  disappearing  in  the  arm,  then  over  the  chest,  until 
only  a  small  area  over  the  heart  remained  (See  Fig.  177).  This 
was  the  area  of  the  third  dorsal  segment  (the  segment  most  fre- 
quently associated  with  lesions  of  the  left  auriculo-ventricular 
opening).  In  cases  of  mitral  disease  I  have  found  it  present  even 
when  the  other  segmental  areas  were  absent.  Another  fact  worthy 
of  attention  is  that  disease  of  the  aorta  seems  to  be  associated  espe- 
cially with  the  first  dorsal  segment.  In  all  cases  it  will  be  ob- 
served that  the  segmental  areas  are  not  as  clearly  defined  as  they 


Cutaneous  hyperal- 
gesia in  cardiac 
disease 


Fig.  178. — Areas  of  Cutaneous  and  Deeper  Hyperalgesia  in  a  Case 
OF  Acute  Dilatation  of  the  Heart,  Accompanied  by  Acute  Dis- 
tention OF  the  Liver. 

are  in  the  figures  in  which  the  distribution  areas  of  the  visceral 
segments  are  shown.  (See  Figs.  2  4  to  26.)  This  is  probably 
due  to  the  fact  that  hyperalgesia  in  cardiac  disease  is  felt  best  in 
the  center  of  the  area  which  is  most  frequently  associated  with 
the  heart ;  and  that  the  intensity  of  the  sensation  gradually  fades 
into  the  adjacent  areas.  In  many  cases  the  cardiac  hyperalgesia 
does  not  exactly  coincide  with  the  area  of  the  cord  zones,  but  may 
overlap  them  or  be  confined  only  to  certain  portions  of  the  zones, 
which  are  most  likely  the  zones  of  maximum  tenderness  of  Head, 


778 


HEART    DISEASE 


In  some  cases  of  heart  disease  there  niaj  also  be  present  an  area 
of  hyperalgesia  on  the  arm  in  the  second  dorsal  segment  and 
another  over  the  heart  in  the  fourth  dorsal  segment,  as  in  Fig. 
177,  wherein  the  hyperalgesia  was  present  on  the  chest,  and  also 
in  a  long  narrow  strip  on  the  anterior  surface  of  the  arm.  In 
this  case  the  area  of  hyperalgesia  most  likely  represented  a  dis- 
appearing zone  of  hyperalgesia.  It  is  in  cases  of  this  kind  that 
hyperalgesic  zones  are  overlooked. 

The  hyperalgesia  may  sometimes  extend  into  the  right  side  or 


Fig.  179. — Hyperalgesic  Area  in  a  Case  in  Which  the  Myocardium  is 
Probably  in  a  State  of  Intoxication. 

The  heart  rhythm  is  slightly  irregular;  at  times  the  first  sound  is  redupli- 
cated, or,  rather,  instead  of  the  normal  first  sound,  there  is  a  double 
first,  with  an  absence  of  the  second.  The  right  side  of  the  heart  is 
also  involved,  a  tricuspid  regurgitant  murmur  being  present. 

up  into  the  neck,  as  in  the  case  of  a  negress  (Fig.  179),  who,  after 
recovering  from  pneumonia,  developed  a  delirium  cordis  with 
variable  pulse  and  a  slight  tricuspid  regurgitation.  Since  the 
right  side  of  the  heart  and  the  great  veins  bear  the  greatest  part 
of  the  stress  of  a  tricuspid  regurgitation  in  lesions  of  this  char- 
acter, the  higher  cardiac  areas  (the  first  and  second  dorsal)  are 
most  frequently  affected,  and  can  be  taken  as  indicators  of  this 
condition.  In  this  connection  it  is  well  to  remember  that  the 
right  ventricle  of  the  heart,  when  diseased,  is  not  so  apt  to  pro- 
duce pain  as  is  the  left  ventricle ;  so  that  i^ain  is  not  as  prominent 
a  diagnostic  symptom  of  right  heart  involvement  as  it  is  of  in- 


GENERAL    CONSIDERATIONS 


779 


volvement  of  the  left.  In  fact,  the  only  symptoms  complained  of 
in  disease  of  the  right  side  of  the  heart  may  be  a  feeling  of 
weight  or  pressure  over  the  cardia,  and  a  tendency  to  take  strong, 
deep  inspirations.     In  some  cases  the  anatomical  structure  of  the 


— — Area     of     sympathetic 

paiu  (from  chest) 


Areas  painful  to  the 
touch.  On  making  pres- 
sure at  times  over  these 
spots  a  very  severe  pain 
was  produced  on  the 
forehead  in  the  left 
frontal  region 


Fig.  180. — Areas  of  Pain  in  a  Case  of  Mitral  and  Aortic  Regurgita- 
tion. 

During  the  last  few  days  previous  to  the  time  at  which  the  outline  was 
made,  the  heart  had  been  acting  very  badly,  and  only  the  night  pre- 
vious to  the  outlining  of  the  pain  areas  the  patient  had  an  attack  re- 
sembling angina  pectoris.  At  these  times  she  also  had  pains  referred 
to  the  labia  on  both  sides  with  painful  urination  and  retention  of  the 
urine.  Examination  of  the  urine  and  the  urinary  organs  showed 
nothing  abnormal. 


heart  may  be  greatly  deranged  without  causing  any  marked  symp- 
toms, as  in  one  case,  in  which  a  column  of  fat  one  inch  in  diam- 
eter extended  through  the  wall  of  the  ventricle,  and  the  only 
symptoms  complained  of  were  a  slight  shortness  of  breath  and  a 
feeling  of  weight  in  the  pericardium.     But,  as  a  general  rule,  it 


780 


HEART    DISEASE 


DIFFERENTIATION   BETWEEN   ACUTE   ENDOCARDITIS  AND 
CHRONIC    AND  RECURRING  ENDOCARDITIS 


Acute 

Chronic 

Fever. 

Present. 

Absent. 

Hypertrophy 
(Heart). 

Absent. 

Present. 

Murmurs. 

Changeable    i  n    character  — 
gradual  increase  in  intensity, 
as    the  diseased  process    ad- 
vances   new    murmurs    may 
make  their  appearance. 

Constant  in  character — 
presystolic  murmur  at 
apex  and  aortic  murmurs 
are  in  favor  of  chronic 
endocarditis. 

Secondary 
phenomena. 

Blood. 

Emboli  are  carried  to  several 
organs  and  give  rise  to  hem- 
orrhagic infarcts  in  the 

1.  Brain. 
Hemiplegia. 
Aphasia. 

2.  Kidney. 
Bloody  urine. 

Pain  in  the  renal  region. 

3.  Spleen. 
Pain. 
Swelling. 

4.  Lungs 
Hemoptysis. 

Circumscribed     dulness, 
generally  at  the  base  of  the 
lung. 

Dyspnea. 

These  are  generally  ushered 
in    by  a    chill;    also   sympa- 
thetic   vomiting     sometimes 
occurs. 

Culture  generally  shows  bac- 
terial growth. 

Secondary  phenomena  are 
due  to  changes  in  the 
valve  segments,  etc.,  and 
manifest  themselves  as 
passive  congestions 
(lungs,  liver,  etc.) 

No  bacterial  growth  on 
culture. 

may  be  stated  that  acute  inflammatory  lesions  of  any  part  of  tlie 
heart  will  produce  reflex  hyperalgesia  in  one  or  all  of  the  cardiac 
zones  of  hyperalgesia. 

This  hyperalgesia  is  of  considerable  value  as  a  prognostic  sign 
in  acute  endocarditis.  Its  disappearance  indicates  the  recession 
of  the  lesion  and  the  return  of  the  parts  to  the  normal.  However, 
it  must  be  borne  in  mind  that  the  absence  of  hyperalgesia  does 


GENERAL   CONSIDERATIONS  781 

not  positively  indicate  an  absence  of  pathology  in  the  heart,  for 
the  pathology  may  be  of  such  a  character  that  it  may  not  produce 
any  cutaneous  hyperalgesia. 

Cardiac  pain  may  also  in  some  cases  be  referred  to  distant 
areas,  as  in  one  case  'where  it  was  referred  to  the  head  in  the 
distribution  area  of  the  fifth  nerve,  being  especially  severe  in  the 
area  of  distribution  of  the  supraorbital  branch  (See  Fig.  180). 

Dilatation  of  the  heart  is  always  painful,  and  causes  hyperal- 
gesia in  the  second,  third,  and  fourth  dorsal,  and  in  the  cervical 
regions,  especially  on  the  left  side.  The  zones  over  the  liver,  the 
seventh,  eighth,  and  ninth  dorsal,  are  also  painful  (see  Liver). 
This  is  due  to  the  congestion  of  the  liver  which  is  always  asso- 
ciated with  a  failing  heart.     Fig.  178  illustrates  the  point  exactly. 

The  diagnosis  between  heart  disease  and  intercostal  neuralgia 
is  sometimes  difficult,  but  is  made  easier  if  the  physician  remem- 
bers that  in  intercostal  neuralgia  the  pain  is  along  the  course  of 
the  intercostal  nerves,  while  in  cardiac  disease  it  has  no  such 
distribution. 

The  differential  diagnosis  is  as  follows :  ? 

Cardiac  Disease.  Intercostal  Neuralgia. 

Pain    is    in    the    cardiac    zone  Xo  pain  in  the  cardiac  areas. 

areas. 

Movement  of  thorax  is  not  espe-  Movement     (respiratory,     etc.) 

cially  painful.  of  thorax  is  painful. 

Pain  does  not   radiate    around  Pain    may    radiate    round    the 

the   chest,    and    the   inter-  chest    and    is    present    on 

costal  spaces  are  not  ten-  pressure  in  intercostal 

der.  spaces. 

Pain,  when  present,  is  more  or  Pain  is  intermittent. 

less  constant. 

Pressure  on  area  of  tenderness  Areas   of   tenderness    are   pres- 

will    not   produce    a    pain  ent,  pressure  on  which  will 

radiating  around  the  chest.  produce   a   pain  radiating 

around  the  ch^st, 


782  HEART    DISEASE 

Intracardiac  Lesions  as  Causes  of  Pain.  — The  raising)  of  the 

intraventricul ar  ienston  often  causes  cardiac  pains.  They  gener- 
ally occur  after  pronounced  exertion,  and  are  rather  common  in 
patients  with  arteriosclerosis  who  have  a  leaking  aortic  valve.  A 
peculiarity  worth  noting  is  that,  as  soon  as  a  mitral  regurgitant 
murmur  develops,  and  an  outlet  is  provided  for  the  increased  intra- 
ventricular tension  consequent  to  extra  muscular  effort,  the  pain 
disappears.  Mitral  regurgitation  often  causes  a  pain  referred 
to  the  left  shoulder  and  down  the  arm.  Palpitation  is  a  frequent 
accompaniment.  The  cause  of  this  pain  may  be  that  early  in, 
and,  in  fact,  during  the  entire  course,  of  the  disease,  the  intra- 
ventricular pressure  in  the  right  ventricle  is  increased,  the  ten- 
sion is  raised,  and  as  a  result  pain  arises  from  the  greater  work 
thrown  upon  the  heart.  (This  may  occur  only  in  stages  of  acute 
loss  of  compensation.) 

Degeneration  of  the  cardiac  ganglia  is  given  as  cause  of  cardiac 
pain  by  W.  H.  Thompson,  who  speaks  of  cases  wherein  severe  pain 
was  felt  in  the  cardiac  region,  with  all  the  signs  of  angina;  and 
yet,  when  death  supervened  during  an  attack,  no  apparent  patho- 
logical abnormalities  could  be  found.  He  suggested  that  a  degen- 
eration of  the  cardiac  ganglia  would  probably  account  for  the 
condition.  (Degeneration  of  these  ganglion  could  have  been 
proved  by  careful  microscopic  examination.) 

In  some  cases  it  is  difficult  to  differentiate  the  pains  of  gastric 
origin  from  those  due  to  cardiac  disease. 

The  following  differential  diagnosis  after  Smith  may  be  useful : 

Pains  of  Gastric  Origin.  Pains  of  Cardiac  Origin. 

Appear  after  food,  and  appar-  Appear    quite    irrespective    of 

ently  are  the  direct  result  whether  food   is   taken   or 

of  its  ingestion.  not. 

Accompanied  by  feeling  of  ful-  No  such  feeling  of  fulness;  not 

ness  in  stomach;  often  re-  relieved   by    eructation    of 

lieved      momentarily      by  wind. 

belching. 


ANGINA    PECTORIS  783 

Pains  of  Gastric  Origin.  Pains  of  Cardiac  Origin. 

JSTot  increased  by  active  move-     Increased  by  active  movements, 
ments,  such  as  walking.  which,  owing  to  the  sever- 

ity of  the  pain,  may  even 
be  impossible. 
Heart  sonnds  normal  in  rhythm     As  a  rule,  some  cardiac  bruit  is 
and  character.  present,   or  at  least   some 

alteration   in  rhythm   and 
volume  of  pulse. 

Because  it  is  the  most  characteristic  of  the  painful  diseases 
of  the  heart,  angina  pectoris  will  next  be  separately  considered. 

ANGINA   PECTORIS 

Etiology. — Angina  pectoris,  which  is  the  most  painful  as  well 
as  the  most  distressing  lesion  of  the  heart,  is  said  to  be  due  to  the 
following : 

(1)  Anemia  of  the  heart  muscle,  which  in  turn  is  the  result 
of  the  narrowing  of  the  coronary  arteries.  This  narrowing  may 
occur  at  their  place  of  origin  at  the  aortic  valves ;  for  instance, 
aortitis,  with  consequent  sclerosis  of  the  aortic  valve,  may  occur, 
and  lead  to  a  partial  closing  of  the  coronary  opening.  The  result- 
ing pain  is  due  to  factors  acting  similarly  to  those  which  cause 
the  pain  in  intermittent  claudication.  Any  condition  causing 
anemia  of  the  cardiac  muscle,  such  as  exhaustion,  bad  health, 
non-assimilation,  etc.,  in  a  person  previously  disposed,  will  fre- 
quently bring  on  this  pain. 

(2)  Irritation  of  nerves  in  the  heart  wall.  These  nerves  are 
of  the  sympathetic  variety,  and  consequently  do  not  carry  direct 
pain  stimuli,  but  only  irritating  ones,  which  are  carried  to  the 
cord  and  from  thence  are  referred  to  the  periphery  as  pain. 

(3)  Exhaustion  of  the  heart  muscle  from  overwork  causes 
pain.  This  pain  is  due  to  the  same  causes  as  the  pain  produced 
in  the  affected  muscles  after  excessive  muscular  fatigue  (Mac- 
kenzie). 


784  HEART    DISEASE 

(4)  In  addition  to  the  above  causes  of  cardiac  pain,  Mac- 
kenzie also  claims  that  angina  pectoris  is  due  to  a  loss  of  con- 
tractability  of  the  cardiac  muscle  fibers. 

(5)  However,  the  direct  exciting  cause  in  angina  pectoris 
seems  to  be  (a)  psychic,  the  result  of  emotion,  such  as  anger  or 
extreme  jov;  or  (b)  physical  overstrain,  such  as  accompanies  the 
lifting  of  excessive  weights,  running  long  distances,  or  the  per- 
forming of  long-continued  exercises. 

Bramwell  (890)  and  Osier  (892)  "seem  to  be  somewhat  in- 
clined to  the  view  that  it  is  the  physical  strain  which  is  the  cause 
of  the  pain  in  angina  pectoris,  because  it  necessitates  extra  work 
by  the  ventricle,  and,  as  a  consequence,  irritation  of  the  cardiac 
nerves. 

(6)  Angina  pectoris  may  also  be  due  to  a  raising  of  the  intra- 
ventricular tension  in  a  weakened  heart.  The  most  frequent  or- 
ganic lesion  of  the  heart  producing  angina  pectoris  is  aortic  re- 
gurgitation and  stenosis,  without  an  accompanying  mitral  lesion. 
When  the  intraventricular  pressure  is  relieved  by  a  mitral  regur- 
gitation the  blood  is  thrown  back  on  the  lungs,  and  the  pain 
ceases. 

Pseudoanginal  pain  also  occurs,  and  is  frequently  due  to 
stomach  disorders.  The  cord  centers  for  the  stomach  are  near  the 
same  level  as  the  cord  centers  for  the  heart,  consequently  the  re- 
flected pain  and  cutaneous  hyperalgesia  for  both  occur  in  the 
same  area,  and  one  is  apt  to  be  mistaken  for  the  other  (Curtin, 
891). 

It  seems  that  cardiac  angina  is  often  brought  on  by  overeating, 
or  by  the  eating  of  unsuitable  or  indigestible  food,  or  food  that  is 
very  apt  to  ferment,  and  thus  cause  dilatation  of  the  stomach, 
which  would  press  up  against  and  inhibit  the  work  of  the  heart. 

Character  of  the  Pain  in  Angina  Pectoris. — In  some  the  sen- 
sation may  not  reach  the  dignity  of  a  pain,  but  is  felt  as  a  creep- 
ing or  a  formication  under  the  skin,  or,  in  other  cases,  as  a 
tingling,  or  coldness  of  the  skin  surface.  When  it  does  approach 
the  magnitude  of  a  pain  it  becomes  very  severe ;  so  much  so  that 
the  suffering  individual  thinks  his  life  is  about  to  terminate.     A 


ANGINA   PECTORIS 


785 


definite  characteristic  of  the  pain  of  angina  pectoris  is  that  it 
almost  always  follows  exertions,  mental  or  physical. 

Location  of  the  Pain. — The  pain  may  be  felt  directly  over  the 
heart ;  in  the  arms ;  in  the  chest  as  a  girdle  sensation ;  in  the 
neck;  in  the  gums  and  throat,  or  in  the  right  side.     Monro  (32) 


Fig.  181. — Area  of  Sensory  Disturbances  in  a  Case  of  Angina  Pectoris. 
A,  analgesia  with  anesthesia;  B,  analgesia  without  anesthesia;  C,  hyper- 
esthesia.    (From  G.  A.  Gibson,  250.) 


mentions  a  case  in  which  there  was  pain  in  the  left  eyebrow  and 
in  the  right  upper  limb.  This  pain  was  accompanied  by  an  in- 
tense desire  to  urinate.  Osier  mentions  a  case  in  which  the  pain 
was  in  the  testicle. 

In  some  cases  a  pain  equal  in  intensity  to  that  usually  felt 
over  the  heart  is  present  in  the  arm  and  is  entirely  absent  over 


786 


HEART    DISEASE 


the  heart.  It  may  start  in  the  little  finger  or  in  the  forearm,  and 
gi-adually  progress  up  the  arm  until  it  passes  over  the  chest  to 
the  cardiac  area,  where  it  may  remain.  In  other  cases  the  pain 
may  be  felt  in  the  chest  in  the  cardiac  area  (third  dorsal  zone), 
and  in  the  forearm  in  the  first  dorsal  area,  the  remainder  of  the 
arm  being  entirely  free  of  pain.     In  other  cases  the  reverse  is 

ACCES^RY  PORTION 

\-  UPPER  GANGLION  OF  VAGUS 

FILAMENT  UN(TlN(b  SPINAL 
ACCeSSORY  TO  OANGHON 
OF    VAGUS. 

•JUGULAR  FOR.  A  MAN 


•SPINAL  PORTION 
ORIGIN   BY  SEVERAL 
FILAMENTS    FR,OMTHE 
LATERAL  TRACTS  OF 
THE  CORD 


•-•CER.VJCAL  PLEXUS 


Fig.  182. — Communication  between  Spinal  Accessory  and  \'agus. 
The  tender  spot  at  the  point  of  emergence  of  the  spinal  accessory  from  the 
sternomastoid   (in  cardiac  disease)  is  probably  due  to  the  close  asso- 
ciation between  the  accessory  and  the  upper  ganglion  of  the  vagus. 


true,  the  pain  being  present  in  the  cardiac  area  on  the  chest  and 
absent  elsewhere.  In  nearly  all  these  cases  there  is  a  peculiar 
constricting  sensation  around  the  chest,  as  though  the  body  were 
wound  with  a  rope  drawn  so  tightly  that  breathing  was  inhibited. 
The  cause  of  this  sensation  is  the  spasmodic  contraction  of  the  in- 
tercostals,  such  contraction  being  explained  by  the  hypothesis  of 
a  visceromotor  reflex.  In  cardiac  disease  pain  may  also  be  felt  in 
the  trapezius  and  the  sternomastoid,  and  in  the  skin  overlyin-^; 
these  muscles.     This  pain  can  be  accounted  for  by  the  close  rela- 


ANGINA   PECTORIS 


787 


tionship  of  the  vagal  centers  in  the  medulla  to  the  centers  of  the 
sensory  nerves  supplying  the  trapezius  and  sternomastoid  muscles, 
so  that  an  irritation  of  the  vagal  centers  will  produce  an  irritation 
of  the  sensory  centers  supplying  the  trapezius  and  sternomastoid 
and  overlying  skin,  and,  as  a  consequence,  pain  will  be  perceived 
in  this  area  (Mackenzie).  In  still  other  cases  pain  has  been 
felt  in  the  gums  and  throat.  It  may  even  be  located  on  the  right 
side  of  the  body,  and  may  appear  on  the  left  side  only  late  in  the 
disease,  or  not  at  all.  According  to  Hoover,  the  pain  in  the  neck 
is  in  the  distribution  area  of  the  third  cervical  segment. 


Spinal  accessory  nerve    ■— 


rPoint    of    tenderness 

in    patient     suffering 

-s  f  r  o  m  cardiovascular 

disease    with  anginal 

^attacks 


Fig.  183. — Emergence  of  the  Spinal  Accessory  from  under  tee  Sterno- 
mastoid. 

This  is  the  point  where  local  tenderness  is  frequently  present  in  cardiac 

disease. 


Local  Tenderness. — In  angina  pectoris  local  tenderness  is  pres- 
ent at  a  point  on  the  border  of  the  sternomastoid,  where  the  spinal 
accessory  becomes  superficial,  and  is  also  present  over  the  second 
and  third  ribs,  about  one  inch  external  to  the  left  sternal  line 
(Hoover). 

Associated  Symptoms. — The  symptoms  associated  with  angina 
pectoris  are:  increase  in  the  flow  of  the  urine  and  saliva,  an 
increased  arterial  pressure,  shock  (indicated  by  pallor,  etc.),  dila- 
tation of  the  pupils,  and  absolute  inability  to  undergo  any  physical 
or  mental  work  during  the  time  of  the  attack.  The  feeling  of 
approaching  death  is  frequent.  .  The  termination  of  the  attack 
may  be  announced  by  the  expulsion  of  the  air  which  has  been 


788 


HEART    DISEASE 


drawn  unconsciously  into  the  stomach  during  the  attack   (Mac- 
kenzie). 

Myocarditis  is  generally  free  of  pain,  though  exertion  is  fre- 
quently followed  by  pain  and  dyspnea. 


%Ly. 


\ 


Fig.  184. — Conducting  Paths  for  Impulses  from  the  Heart. 
The  figure  shows  the  relationship  existing  between  the  heart,  the  pupillary 
reactions,  and  the  radiation  into  the  arm.  DP,  the  pupil  dilating  cen- 
ter in  the  base  of  the  brain;  DP,  radiating  fibers  of  the  iris;  MM,  muscle 
of  Miiller;  LP,  non-striped  portion  of  the  levator  palpebrse;  S,  indicates 
the  method  of  radiation  into  the  arm.  (Copied) 

DISEASE  OF  THE   PERICARDIUM 

In  disease  of  the  pericardium  pain  may  be  entirely  absent. 
When  present  it  is  located  in  one  of  the  areas  of  reflected  cardiac 
pain.  A  characteristic  of  pericardial  disease,  not  so  frequently 
present  in  heart  muscle  or  endocardial  involvement,  is  that  tender- 
ness is  marked  over  the  cardiac  area,  especially  so  should  a  medi- 
astino-pericarditis  be  present.     In  this  condition,  where  the  in- 


DISEASE    OF    THE   PERICARDIUM  789 

flammation  lies  so  close  to  the  chest  wall,  pain  and  tenderness 
are  present  over  the  third  rib  on  the  left  side,  and  extend  about 
one  to  two  inches  from  the  left  sternal  border.  This  is  also  the 
area  which  Hoover  gives  for  tenderness  in  angina  pectoris,  and 
which  Head  gives  for  the  maximal  tenderness  in  the  third  dorsal 
zone  (anterior).  This  accord  is  wonderful  when  it  is  considered 
that  the  location  of  these  areas  has  been  worked  out  from  different 
premises,  Head's  area  being  considered  as  the  result  of  a  stimulus 
acting  reflexly  through  the  cord,  while  Hoover's  areas  are  re- 
garded as  the  places  where  the  local  tenderness  is  most  marked. 
The  tenderness  of  the  skin  and  subjacent  tissues  in  pericarditis 
extends  for  a  considerable  distance  lateral  to  the  right  sternal 
margin.  The  pericardium  of  itself  is  insensitive  to  all  ordinary 
stimuli,  as  Richeraud  has  claimed  and  as  many  others  have  found 
(during  operations). 


CHAPTER  XXXV 

THE  EESPIKATOEY  OEGANS 

THE  LUNGS 

GENERAL 

Etiology  of  Lung  Pain. — Pain  in  the  segmental  areas  asso- 
ciated with  the  lungs  may  be  the  earliest  indication  of  a  pul- 
monary involvement,  though  in  many  cases  there  may  be  no  actual 
pain  manifestation,  but  only  a  feeling  of  discomfort  in  the  chest 
wall.  It  seems  that  pain  is  not  as  common  in  lung  disease,  with 
the  exception  of  pneumonia,  as  it  is  in  disease  of  the  heart.  When 
it  is  present  many  causes  are  assigned,  the  principal  one  being  an 
inflammation  of  the  pleura.  That  this  is  a  very  important  factor 
in  the  production  of  lung  pain  can  hardly  be  doubted,  in  view  of 
the  almost  universal  association  of  a  pleurisy  in  those  lung  dis- 
eases in  which  pain  is  a  prominent  symptom.  Yet  the  visceral 
pleura  of  itself  has  very  little  sensation,  as  can  be  demonstrated 
during  the  removal  of  a  pleural  exudate,  when,  should  the  pleura 
come  in  contact  with  the  tip  of  the  cannula,  no  pain  results.  Mac- 
kenzie says  that  in  several  cases  he  has  made  careful  dissections 
of  the  intercostal  nerves,  following  them  to  their  terminations, 
and  that  in  no  case  could  he  find  "a  single  filament  going  to  the 
pleura."  He  suggests  that  the  referred  pain  of  basal  pleurisy 
may  be  due  to  the  invasion  of  the  diaphragm  by  the  inflammation. 

Distribution  of  Referred  Pain.^ — If  such  is  the  cause,  the  pain 
of  pleural  disease  must  be  produced  in  the  parietal  subjacent 
pleural  tissue,  and  be  carried  through  some  of  the  branches  of  the 
intercostal  nerves,  which,  though  not  directly  connected  with  the 
pleura,  are  found  ramifying  in  the  subpleural  connective  tissue 
(Johnston,  538).  If  this  were  so  we  should  expect  to  find  pleural 
790 


THE   LUNGS 


791 


pain  referred  to  the  points  of  maximum  tenderness  of  the  inter- 
costal nerves ;  that  is,  to  the  points  where  the  nerves  become  super- 
ficial. !Now,  if  v^e  examine  a  case  of  pleurisy,  with  pain  produc- 
tion, we  find  that  this  is  true,  the  pain  due  to  pleural  lesions  be- 
ing most  often  felt  in  the  anterior  axillary  line,  which  corre- 
sponds fairly  well  with  the  line  of  the  points  of  emergence  (areas 


A.       N.    cut. 
brach.  med. 

B,       N.     inter- 
costo-brach. 

A 

C,  N.  thoracalis 
longua 

B 

D,    Ramus  cut. 
lat.        (pect.) 
intercostalis 

C 
D 

E,  Post,  ramus 
of  the  ramus 
of  the  cut.  lat. 

E 
F 

F,  LatissimuB 
dorse 

G 

G,    Ramus  cut. 
lat.  (pect.)  N. 
intercost.  VII 

H 

H,  N.  intercost. 
IX 

I,  N.  intercost. 
XI 

I 

J,   N.  intercost. 
XII 

J 

K,     L,  N.  ilio- 
hypogastric. 

K 
L 

M,  Ramus  cut. 
ant.  (pect.) 
N.  intercost, 
I 

N,  M.  pecto- 
ralis  major 

O,  Ramus  mam. 
med. 

P,  M.  serratus 
ant. 

Q,  Ramus  cut. 
ant.  (pect.) 
N.  intercost. 
VII 

R,  M.  rect.  ab- 
dom. 

S,  Linea  alba 

T,  Rami  cut. 
ant.  (abdom.) 
N.  intercost. 
IX 

U,  Umbilicus 

V,  Appendix 
area 


Fig.   185. — Points  of  Emergence  op  the  Dorsal  Nerves  (Anterior). 
These  points  are,  as  a  rule,  the  places  where  pain  is  complained  of  when 
the  thoracic  nerves  are  irritated.    Generally,  tenderness  is  also  present 
in  the  skin  immediately  'over  these  areas.     (Spalteholz,  Leipzig,  1909, 
vol  3.) 


of  greatest  tenderness)  of  the  intercostal  nerves.  Sowever,  be- 
cause of  the  close  relationship  of  the  parietal  and  visceral  pleura 
it  is  almost  impossible  for  one  to  be  diseased  without  the  other 
being  affected,  so  that  we  always  find  both  taking  part  in  the 
inflammatory  process. 

When  the  parietal  pleura  is  inflamed  it  is  very  easy  for  the 
inflammatory  process  to  spread  and  involve  the  intercostal  nerves, 
and  thus  cause  an  intercostal  neuritis.  Should  this  occur,  tender- 
ness is  present  in  the  intercostai  spaces,  is  most  marked  at  the 


792  THE   RESPIRATORY    ORGANS 

anterior  axillary  line,  and  extends  out  onto  the  anterior  wall  of 
the  chest.  Pain  is  also  felt  in  this  area,  but  lies  more  toward  the 
sternal  margin.  When  the  lower  part  of  the  pleura  is  involved 
resjjiration  becomes  very  painful.  This  is  due  to  the  constant 
friction  of  the  parts,  and  the  slight  pressure  and  traction  made 
upon  the  supersensitive  intercostal  nerves  during  each  respiratory 
act. 

Pain  due  to  inflammation  of  the  visceral  pleura  is  not  direct, 
but  is  referred,  through  the  sympathetic  nervous  system,  to  the 
cord,  and  thence  back  to  the  chest  wall  through  the  spinal  nerves. 
This  reference  pain  is  located  in  one  or  more  sharply  defined 
areas,  the  so-called  Head  zones. 

The  zones  in  relation  with  the  lungs  or  pleura  are  those  of  the 
first  seven  dorsal  segments  of  the  cord.  The  maximum  points 
of  tenderness  of  these  zones  are  the  places  where  the  patient  fre- 
quently feels  the  most  severe  subjective  pain.  That  all  these 
zones  are  involved  to  an  equal  degree  in  disease  of  the  lung  or 
pleura  cannot  be  held.  Indeed,  it  seems  more  than  likely  that 
the  only  zone  almost  constantly  involved,  either  in  visceral  pleural 
disease  or  in  disease  of  the  lung  itself,  is  the  fourth  dorsal, 
which  has  its  area  of  maximum  tenderness  slightly  above  and 
external  to  the  nipple,  the  point  where  the  patient  complains  of 
the  greatest  pain.  How  true  it  is  that  the  physician  often  sees 
cases  which  begin  with  a  chill,  followed  shortly  by  a  rise  of  tem- 
jjerature  and  an  increase  of  pulse  rate,  and  which,  with  the  excep- 
tion of  a  cough,  have  no  sign  of  lung  involvement,  except  the 
pain  in  the  chest  above  and  external  to  the  nipple !  And  yet  after 
two  or  three  days  typical  signs  of  pneumonia  appear.  To  those 
who  are  not  aware  of  the  relationship  of  pain  and  pulmonary 
disease  it  is  surprising  to  find  that  the  area  of  greatest  pain  does 
not  always  correspond  with  the  location  of  the  lesion;  yet,  from 
our  previous  knowledge,  it  is  easy  to  explain  this  apparently 
erratic  reference. 

If,  on  careful  examination,  no  pleural  friction  rub  or  other 
sign  of  pleurisy  at  the  place  where  the  pain  is  felt  can  be  found, 
how,  otherwise,  in  the  absence  of  other  symptoms,  can  this  chief 


THE    LUNGS 


793 


pain  be  accounted  for,  except  under  the  hypothesis  that  through 
the  sympathetic  stimuli  are  carried  to  the  cord,  and  are  thence 
referred  back  to  the  body  walls  through  the  somatic  nerves  and 
are  there  perceived  as  pain  ? 

A  serous  pleurisy  of  considerable  magnitude  may  exist  with- 
out giving  rise  to  the  slightest  pain.  This  has  been  exemplified 
in  many  cases.     They  were  all  the  result  of  chronic  disorders, 


,''V\ 


Fig.  186. — Areas  ofHyperalgesiain  a  Case  of  Diaphragmatic  Pleurisy. 


and  were  associated  with  a  backward  stasis  from  a  failing  heart. 
In  acute  pleurisy  pain  is  always  a  prominent  symptom. 

In  inflammation  of  the  pleura,  over  the  diaphragm  and  adja- 
cent to  the  mediastinum,  the  phrenic  nerve  may  become  irritated. 
When  this  occurs  the  irritation  is  conveyed  to  its  center ;  and  since, 
according  to  Van  Gehuchten,  the  phrenic  conveys  sensory  fibers, 
the  stimulation  may  be  felt  as  coming  from  its  peripheral  distri- 
bution in  the  diaphragmatic,  pericardiac,  and  costal  pleura. 

If  the  diaphragm  alone  is  involved  in  the  pleurisy  the  pain  is 
conveyed  through  the  tenth,  eleventh,  and  twelfth  thoracic  nerves, 
and  is  referred  to  their  area  of  distribution  in  the  lower  abdom- 
inal wall. 


79i 


DISEASES    OF    THORACIC    ORGANS    CAUSING   PAIN     795 

Of  these  the  tenth  is  the  nerve  most  frequently  involved.  The 
pain  is  of  a  characteristic  dull,  aching  type.  It  may  he  stated  as 
an  aphorism  that  as  a  rule  only  acute  diseases  of  the  lung  and 
pleura  produce  pain,  and  that  chronic  diseases  are  painless. 

DISEASES    OF    THORACIC    ORGANS    CAUSING    PAIN 

The  acute  diseases  most  commonly  producing  thoracic  pain  are : 
lesions  of  the  j)leura,  as  acute  inflammation,  empyema,  adhesions 
(diaphragmatic,  costal),  and  diseases  of  the  lungs,  which  are: 
acute  bronchitis,  pneumonia,  and  tuberculosis.  Pain,  as  a  rule, 
is  not  a  prominent  symptom  in  the  following  chronic  diseases: 
chronic  bronchitis,  bronchiectasis,  asthma,  emphysema,  chronic 
tuberculosis,  chronic  pleurisy,  hydrothorax,  and  new  growths, 
either  of  the  lung  or  of  the  pleura. 

Acute  bronchitis,  localized  exactly  in  the  bronchi,  causes  pain, 
which  is  referred  to  the  same  somatic  areas  as  is  the  pain  of 
parenchymatous  pulmonary  disease.^  But  since  all  cases  of  bron- 
chitis involve  the  trachea  to  a  greater  or  less  degree,  the  pain 
is  felt  also  in  the  area  of  distribution  of  the  nerves  supplying  this 
organ.  These  nerves  are  the  pneumogastric  with  its  recurrent 
branches  and  the  sympathetic.  It  is  evidently  the  referred  sensa- 
tion from  the  trachea  through  the  sympathetic  to  the  skin  of  the 
neck  and  the  uj^per  part  of  the  chest  that  is  the  cause  of  the  ach- 
ing and  soreness  in  these  regions,  complained  of  so  much  in 
tracheitis  and  bronchitis.  A  pnin  in  the  lower  part  of  the  thorax, 
or  in  the  upper  part  of  the  epigastrium,  is  also  present  at  times 
in  bronchitis.  This  pain  is  the  result  of  the  traction  and  pull  on 
the  ribs  and  costal  cartilages  made  by  the  abdominal  muscles  and 
the  diaphragm  in  the  act  of  coughing.  It  is  present  only  in 
severer  forms  of  bronchitis,  which  are  accompanied  by  consider- 
able coughing.  As  bronchitis  is  often  but  a  localization  of  a  gen- 
eralized infection,  pains  due  to  this  infection  may  at  the  same 
time  be  present  in  other  parts  of  the  body.  These  pains  are  due 
to  the  general  toxemia,   and   are  not  caused  by  the  bronchitis, 

'  Head   gives  the   second   dorsal   visceral   segment    as   related   to  bronchial 
disease. 


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DISEASES    OF    THORACIC    ORGANS    CAUSING   PAIN     797 

which,  in  the  general  involvement,  is  but  a  factor.  Chronic 
bronchitis  is  without  pain-phenomena.  When  pain  is  present  it 
is  due  either  to  a  myalgia  or  an  intercostal  neuralgia. 

Pneumonia. — Pneumonia  practically  always  is  productive  of 
pain.  Even  the  so-called  central  pneumonia  causes  pain.  The 
pain  of  pneumonia  varies.  In  some  cases  it  is  an  aching  and  a 
dragging  felt  in  the  fourth  dorsal  visceral  zone,  while  in  others 
it  extends  up  into  the  first,  second,  and  third  dorsal  zones.  It 
may  also,  according  to  Head,  be  found  in  the  fifth,  sixth,  and 
seventh  dorsal  zones.  Owing  to  the  co-association  of  these  lower 
cord  zones  with  the  lungs,  the  liver,  and  the  stomach,  lesions  of 
the  lungs  frequently  give  rise  to  hepatic  and  gastric  symptoms, 
and  cause  some  confusion  as  to  which  of  these  organs  is  involved. 
In  involvement  of  these  zones  the  pain  is  frequently  felt  in  the  epi- 
gastrium or  low  down  on  the  same  side  of  the  chest  as  the  lesion. 
There  are  also  present  in  these  zones  maximal  points  of  tender- 
ness, in  which  pain  is  felt  subjectively  by  the  patient,  and  in 
which  the  skin  is  exquisitely  tender  to  the  touch.  It  is  in  these 
areas  of  maximum  tenderness  that  pain  is  often  referred  in  pneu- 
monia. In  central  pneumonia  these  areas  of  pain  may  be  the  only 
indications  (in  the  early  stages)  of  the  pneumonic  involvement. 
Other  forms  of  pneumonia  are  generally  associated  with  a  pleu- 
risy, and  the  pleurisy  generally  monopolizes  the  pain  syndrome  to 
such  an  extent  that  the  pain  of  the  pneumonia  proper  is  over- 
looked. When  pleurisy  is  present  tenderness  may  be  marked  over 
the  diseased  area,  so  that,  therefore,  the  associated  pleuris}'  in 
pneumonia  may  give  rise  to  pain  felt  either  locally  or  referred 
to  the  abdomen  (iliac  region).  This  latter  has  been  mistaken  for 
appendicitis  pain.  This  probably  occurs  only  when  the  diaphragm 
is  involved  in  the  inflammatory  process,  in  which  case  the  twelfth 
intercostal  nerve  is  irritated,  and  the  stimulus  is  perceived  as 
coming  from  its  terminal  filaments,  which  are  distributed  over 
the  area  usually  associated  with  appendix  disease.  A  reference 
of  this  kind  frequently  takes  place  in  children,  and  when  associ- 
ated with  abdominal  rigidity,  chills,  elevation  of  temperature,  and 
a  rapid  pulse  is  apt  to  lead  to  the  diagnosis  of  appendicitis.     This 


798  THE   RESPIRATORY    ORGANS 

is  all  the  more  likely  when,  as  in  many  cases^,  the  signs  of  the 
pneumonia  do  not  ajopear  until  tweuty-fonr  to  forty-eight  hours 
after  the  onset  of  the  disease. 

Janeway,  Osier,  Frantzel,  Cozolina  (492),  Barnard,  Hampe- 
lin,  Brewer,  Richardson  (491),  Massalong  (490),  Lovett  (494), 
Ginnon  (493),  Comby  and  Zielenski  (495),  all  report  cases  of  this 
character.  Yet  a  mistake  of  this  kind  is  almost  inexcusable,  for  in 
nearly  all  of  these  cases,  upon  a  thorough  examination,  signs  of  dis- 
ease may  be  found  in  the  thorax.  In  pneumonia,  also,  the  rusty 
sputum,  expiratory  grunt,  cough,  rapid  respiration  which  is  out  of 
all  proportion  to  the  pulse  (respiration  may  be  forty  to  sixty  and 
the  pulse  only  a  hundred  to  a  hundred  and  ten),  and  sudden,  high 
elevation  of  temperature  clearly  point  to  the  correct  diagnosis. 
Another  diagnostic  sign  of  value  is,  that,  in  those  cases  in  which 
the  lung  is  diseased,  there  is  noticed  a  slight  reduction  in  the  rigid- 
ity of  the  abdominal  wall  at  the  beginning  of  inspiration.  This  is 
not  present  in  cases  of  abdominal  inflammatory  disease.  The 
abdominal  wall  in  pneumonia  also  is  sensitive  to  superficial  pres- 
sure and  insensitive  to  deep  pressure.  Rings  are  absent  from 
around  the  eyes,  and  a  flushing  of  the  cheek  on  the  affected  side 
is  generally  seen. 

In  reference  to  the  confusion  of  these  two  diseases,  Rodman, 
in  a  discussion  on  referred  pain  before  the  Pennsylvania  State 
Society,  said  that  everyone,  perhaps,  has  made  mistakes  in  diag- 
nosing pneumonia  as  appendicitis.  He  spoke  of  one  case,  a  man 
with  an  acute  pneumonia,  in  whom  pain  in  the  abdomen  was  the 
most  prominent  symptom.  He  was  asked  to  see  the  case  as  one 
of  appendicitis,  and  concurred  in  the  diagnosis.  He  was  also 
impressed  with  the  fact  that  the  man  had  a  beginning  pneumonia, 
and  declined  to  operate,  believing  that  the  patient's  chances  would 
be  best  subserved  by  carrying  him  through  the  pneumonia  and 
operating  for  the  appendicitis  afterward.  Another  physician  who 
was  called  in  did  not  concur  in  this  opinion,  especially  as  the 
abdominal  symptoms  increased  in  severity,  and  as  the  pain  was 
very  severe  and  did  not  yield  to  a  large  hypodermic  injection  of 


DISEASES    OF    THORACIC    ORGANS    CAUSING   PAIN     799 

mor23hin.  An  operation  was  performed,  and  the  appendix  was 
found  to  be  practically  normal. 

A  case  of  referred  pain  in  pneumonia  was  reported  to  me  by 
McFarland.  It  was  of  a  child,  four  years  of  age,  in  whom  the 
pain  was  over  McBurney's  jDoint  Signs  of  consolidation  were 
present  at  the  base  of  the  posterior  jDart  of  the  right  lung. 

In  anothei*  patient,  suffering  from  bronchopneumonia,  the 
pain  complained  of  was  half  way  between  the  xiphoid  cartilage 
and  the  umbilicus. 

In  these  cases  of  referred  pains  the  diagnosis  is  all  the  more 
difScult  should  the  pneumonic  lesion  be  centric,  though  from  the 
absence  of  local  abdominal  tenderness  and  the  freedom  from 
vomiting,  etc.,  with  the  presence  of  rapid  respiration,  increased 
pulse  rate,  and  coughing,  the  lungs  should  be  considered  as  at 
fault,  and  a  most  searching  examination  made. 

One  differentiating  characteristic  between  abdominal  disease 
and  pneumonia  with  referred  abdominal  pain  is  that,  in  the  pneu- 
monia, the  skin  over  the  painful  area  is  very  hypersensitive,  but 
deep  pressure  can  be  made  over  it  without  causing  much  pain; 
while  in  appendicitis  both  superficial  and  deep  pressure  are  very 
painful.  Another  characteristic  of  pneumonia  is  that  the  ab- 
dominal pain  disappears  as  the  pulmonary  signs  become  more 
pronounced  (Hood,  Lancet,  1905). 

The  pain  of  pneumonia  may  also  be  felt  in  the  neck  and  shoul- 
ders. In  some  cases  it  may  be  transferred  entirely  and  be  felt  on 
the  side  of  the  chest  opposite  to  that  of  the  lesion.  Such  a  trans- 
ference is  very  common  in  infants.  In  infancy,  pain  is  of  doubt- 
ful value  in  making  a  diagnosis,  because  of  its  irregular  location 
and  frequently  late  appearance,  for  in  many  cases  it  does  not 
appear  until  from  three  to  five  days  after  the  onset  of  the 
disease. 

In  some  patients  the  pain  present  during  pneumonia  persists 
for  long  periods,  after  all  the  physical  signs  of  the  disease  have 
disappeared.  This  continuance  in  the  majority  of  cases  is  due  to 
fibrous  changes  in  the  lung,  or  to  adhesions.  In  a  case  of  Anders, 
pain  in  the  cardiac  region,  persisting  for  four  months  after  the 


800  THE    RESPIRATORY    ORGANS 

crisis,  was  shown,  by  tlie  Roiitgen  rays,  to  be  due  to  a  fibrous  band 
stretching  between  the  diaphragmatic  pleura  and  the  pericardiac 
sac. 

Tuberculosis.— In  the  early  stages  of  tuberculosis,  during  ul- 
cer formation,  pain  is  not  so  likely  to  be  present  as  during  the 
later  stages,  after  an  abscess  has  formed.  At  this  later  date,  also, 
a  pleuritis  is  more  likely  to  be  present,  especially  so  if  the  tuber- 
cular lesion  is  in  the  apex.  It  is  for  this  reason  that  pain  in  the 
supra-  and  infraclavicular  regions  is  so  often  an  early  sign  of 
pulmonary  tuberculosis.  During  the  second  stage  of  tuberculosis 
the  whole  half  of  the  chest  on  the  affected  side  has  a  tired,  aching 
feeling,  not  increased  on  deep  breathing.  It  is  during  this  stage, 
also,  that  pain  is  often  a  prodrome  of  hemoptysis.  The  reason 
for  this  may  be  that,  prior  to  the  hemorrhage,  the  lung,  as  the  re- 
sult of  increased  arterial  tension,  is  in  a  state  of  congestion,  and 
this  gives  rise  to  pain.  After  the  hemorrhage  the  congestion  is 
relieved  and  the  pain  disappears.  Coughing,  likewise,  possibly 
for  the  same  reason,  frequently  increases  the  pain.  The  pain 
most  commonly  associated  with  coughing  is  localized  to  the  area 
of  insertion  of  the  recti  muscles  into  the  costal  borders.  In  some 
cases  of  pleurisy  the  inflammation  spreads  to  the  intercostal 
nerves  and  a  neuritis  develops;  the  pain  is  now  felt  over  the 
lateral  and  anterior  parts  of  the  chest.  The  branches  joining 
the  nerves  of  the  arm  to  the  second  and  third  intercostal  nerves 
may  also  become  involved,  and  then  the  pain  runs  do"\\Ti  the  inner 
side  of  the  arm,  in  the  area  of  distribution  of  the  nervi  intercosto- 
brachiales    (intercostohumeral  nerves). 

Character  of  the  Pain  in  Pulmonary  Tuberculosis. — In  some 
cases  there  may  be  only  a  sense  of  discomfort  or  a  feeling  of  dis- 
tress in  the  chest,  while  in  others  actual  pain  may  be  present. 
In  many  there  is  a  sensation  as  though  the  pain  extended  all  the 
way  through  to  the  back.     It  may  be  constant  or  fleeting. 

Tenderness  is  a  marked  feature  of  early  pulmonary  tubercu- 
losis; and,  according  to  Francke,  appears  before  many  of  the 
other  symptoms.  Tenderness  is  elicited  by  percussion,  and  is  most 
marked  in  the  apex.    It  is  probably  due  to  involvement  of  the  sub- 


DISEASES    OF    THORACIC    ORGANS    CAUSING   PAIN     801 

jacent  pleura.  This  percussion  pain  Francke  found  present  in 
about  77.9  per  cent,  of  all  eases  of  pulmonary  tuberculosis.  When 
search  for  this  percussion  is  to  be  made  high  up  over  the  back, 
the  anterior  fibers  of  the  trapezius  are  displaced  to  one  side,  by 


Pain  and  tender- 
ness in  pulmo- 
nary tuberculosis  J 


Pain  felt  here  on 
percussion  over  the 
lungs 


Area  of  maximum 
tenderness  in  heart 
disease 


Fig.  191. — Some  op  the  Areas  of  Pain  and  Tenderness  in  Cardiac 
AND  Pulmonary  Disease. 


having  the  patient  bend  forward  and  fold  his  arms,  so  that  the 
percussion  blows  may  be  made  as  directly  as  possible  over  the 
chest. 

x^ccording  to  Klebs,  in  pulmonary  tuberculosis  tenderness  is 
very  common  above  the  clavicles,  anteriorly  and  posteriorly,  and 
between  the  scapula  posteriorly.     A  pain  above  the  shoulder  is 


802  THE   RESPIRATORY    ORGANS 

felt  with  each  cough,  and  pain  on  every  movement  of  the  arm  may 
be  present  and  is  often  mistaken  for  rheumatism. 

Other  causes  of  thoracic  pain  in  pulmonary  tuberculosis  may 
be  myositis,  nervous  erethism,  pulmonary  congestion,  pressure 
from  enlarged  glands,  localized  fatigue  of  the  muscles  used  in 
respiration  or  in  coughing,  contraction  of  old  cavities,  traction  by 
adhesions  to  j)leura  or  to  the  heart,  pneumothorax,  tuberculosis  of 
the  ribs,  and  referred  pain. 

The  intercostal  muscles  may  also  become  involved  in  the  in- 
flammatory process,  and  intercostal  myositis  may]  develop.  The 
muscles  are  now  extremely  painful  to  touch  or  to  movement,  and, 
owing  to  the  jiain,  resjiiration  is  restricted. 

If  a  pleurisy  has  ensued  during  the  lung  involvement,  and  ad- 
hesions have  formed  between  the  pleura  and  the  pericardia,  pain 
results.  This  may  be  felt  both  during  respiratory  movements  and 
cardiac  contractions ;  in  fact,  it  is  pathognomonic  of  this  variety 
of  pain  that  it  has  an  alternating  character,  due  to  the  variation 
of  pressure  from  the  changed  relationship  of  the  heart  to  the  sur- 
rounding tissues.  Pressure  over  the  places  where  traction  is  made 
upon  the  chest  wall  by  the  adherent  pericardium  and  pleura  is 
painful. 

When  during  tuberculosis  a  pneumothorax  results,  a  sudden, 
agonizing  pain  is  felt.  This  may  be  so  severe  that  it  resists  all 
medication,  even  morphin.  It  is  said  by  Clement  that  pronounced 
neuralgia,  marking  the  onset  of  tuberculosis,  is  a  very  grave 
prognostic  symptom.  L.  Brown  claims  that  a  stubborn  pain,  when 
coincident  with  a  poor  general  condition,  chills,  and  fever,  is  fre- 
quently an  indication  of  a  deep  focus  which  is  extending  toward 
the  periphery  of  the  lung. 

THE  MEDIASTINUM 

The  mediastinal  diseases  causing  pain  arc  aneurysm,  medias- 
tinal inflammation,  abscess,  and  enlargement  of  the  mediastinal 
glands.  The  pain  comjDlained  of  is  both  local  and  reforrtd.  The 
local  pain  is  due  to  the  pressure  of  the  gi-owths  on  the  surrounding 


THE   MEDIASTINUM  803 

structures,  which,  in  turn,  causes  pressure  on  the  anterior  chest 
wall  and  jDain  production.  The  referred  pain  is  due  to  involve- 
ment of  the  nerves  in  the  diseased  process.  Pain  is  common  in 
the  epigastrium,  and  may  be  j^resent  in  the  early  stages.  Pain 
may  also  be  present  in  the  back.  In  one  case  of  mediastinal  sar- 
coma it  was  present  on  each  side  of  the  chest  over  the  scaj)uliae. 
In  some  cases  of  mediastinal  tumors,  especially  in  those  of  a  ma- 
lig-nant  nature,  the  pain  is  due  to  an  intercostal  neuralgia,  the 
result  of  infiltration  of  the  intercostal  nerves  by  the  tumor  cells. 
Aneurysm  of  the  arch  of  the  aorta,  or  of  the  thoracic  aorta,  ca-uses 
but  few  painful  symptoms  except  those  due  to  pressure.  When 
the  aneurysm  extends  and  lies  just  beneath  the  sternum,  and 
begins  to  push  its  way  through,  causing  necrosis  of  the  bone,  a 
boring,  gnawing  pain  is  felt.  At  this  time  marked  tenderness 
over  the  diseased  area  is  present.  The  esophageal  pains  have 
been  described  under  the  esophagus   (q.  v.). 


BIBLIOGRAPHY 

Abbe,  E.  "Eesection  of  the  Posterior  Eoots  of  the  Spinal  Nerve  to 
Eelieve  Pain.  Pain  Eeflex,  Athetosis  and  Spastic  Paralysis. 
Dana's  Operation."     Medical  Eecord,  Mar.  4,  1911,  377. 

Acker,  G.  B.  "Vague  Pain  and  Muscular  Aches."  iSTew  Eng.  Med. 
Month.,  Danbury,  Conn.,  xxiii,  51-53. 

AcKLAND,  A.  W.  E.  (595).  "Notes  on  Some  Cases  of  Neuralgia." 
British  Med.  Jour.,  London,  1907,  ii,  1499-1501. 

Adami  (603).     "Sciatica."     "Pathology,"  1st  ed.,  ii,  1028. 

Addison.  Quoted  by  J.  W.  Byers.  British  Med.  Jour.,  Nov.  8,  1902, 
1562. 

Albrecht,  H.  "Habit  Pains."  Zentralbl.  fiir  Gynacologie,  Leipzig, 
Jan.  14,  1911,  xxxv,  No.  2,  50;  Ab.,  J.  A.  M.  A.,  Feb.  18,  1911, 
Ivi,  No.  7,  552. 

Aldrich,  W.  J.  "iVcute  Epigastric  Pain."  Vermont  Med.  Month., 
Burlington,  1908,  xiv,  141-144. 

Alger  (560).     Med.  Eecord,  June  8,  1907. 

Allaben  (741).  "Intestinal  Perforation  in  Typhoid  Fever,  Its  Diag- 
nosis and  Surgical  Treatment."    J.  A.  M.  A.,  xlix. 

Allbutt   (815).     "System  of  Medicine,"  iii,  47. 

Allen,  A.  E.  (907).    British  Med.  Jour.,  Mar.  17,  1906,  619. 

■ .    (609).      "The    Symptom-Complex   of    Transverse    Lesions    of 

the  Cord  and  Its  Eelationship  to  Structural  Changes  Therein." 
Am.  Jour.  Med.  Sci.,  Philadelphia,  1908,  cxxxv,  735-739. 

.      "Injuries  of  the  Spinal  Cord:  A  Study  of  Nine  Cases  with 

Necropsy."     J.  A.  M.  A.,  1908,  i,  941-952. 

Allen  (563).    "Science  History  of  the  Universe,"  vi,  157. 

Allen,  Thos.  H.  "Medicine;  Mythological  Pain;  Celts  and  Teu- 
tons."    "Science  History  of  the  Universe,"   vii,   120. 

^  The  figures  enclosed  in  parentheses  immediately  following  a  name  were 
first  used  as  a  means  of  reference  by  the  author,  and  later  were  retained — in 
case  a  reference  to  the  same  author  is  used  in  more  than  one  place  as  a  means 
of  identification  of  the  reference — as,  for  instance,  under  Osier  we  find  many 
references — each  identified  by  the  number  which  follows.  The  numbers  have 
nothing  to  do  with  the  pages  in  the  text. 

805 


806  BIBLIOGRAPHY 

Allison,  N.     "Anterior  Metatarsalgia,  Its  Causes  and  Its  Eelief." 

Boston  Med.  and  Surg.  Jour.,  1909,  clx,  229-232. 

.     Med.  Xews,  1891.  xxv,  217. 

Aleutz,    S.      "■Untersuchungen    iiber    Schmerzpunkte   und    doppelte 

Sehmerzempfindungen."     Arch.  f.  Physiol.,  Leipzig,  1905,  xvii, 

414-430. 
Aleutz,  S.  G.     "Ueber  Schmerz  und  Schmerznerveu,  Eine  kritische 

Historik."    Arch,  f,  Physiol.,  Leipzig,  1905,  xviii,  1-46. 
Aleutz,  S.  G.  L.  R.     "Undersokninejor  ofver  smartsinnet"    ("Re- 
searches on  the  Sense  of  Pain").     Upsala,  1901. 
Aly,  "Zur  Priifung  der  Schmerzempfindlichkeit  des  Drucksinnes  und 

der  Beriihrungsempfindlichkeit."    Illustr.  Monats.  d.  arztl.  Poly- 

technik,  Berlin,  1898,  xx,  183. 
Andeeson,  McC.  (860).    "Cases  Illustrative  of  Pain  as  a  Symptom 

of  Disease."    Lancet,  London,  1873,  ii,  73. 
Andeew-Bied,  Letitia  H.     "A   Curious   Case   of   Foot   Soreness," 

Lancet,  London,  1909,  I,  365. 
Andbews,  C.  R.,  and  Hoke,  M.   (806).     "Lumbar  Pain."     Atlanta 

Journal-Record,  August,  1908. 
Andeews,  Edmund  (327).     "Studies  on  Rendering  Incisions  Pain- 
less by  Means  of  High  Velocity."    Trans.  Am.  Med.  Ass.,  1877, 

28,  55. 
Anstie.     "Neuralgia  and  Its  Counterparts." 

.     "Perturbation  of  Nerve  Function." 

Anton  (866).     "Ueber  den  einseitigen  Korperschmerz."     Mitth.  d. 

Ver.  d.  Aerzte  Steiermarks,  Graz,  1899,  xxxvi,  6-8. 
Aechambault,  L.     "La  douleur."     Jour,  de  la  Sante,  Paris,  1905, 

xxii,  893-897. 
AsHTON  (735).    "Gynecology,"  1906,  661. 
Atkinson,  J.     "Pain  and  Its  Treatment."     Practitioner,  London, 

1870,  V,  58-88. 
Atlee,  W.  L.     "Dietl's  Crisis  and  Some  Cases  of  Movable  Kidney." 

New  York  Med.  Jour.,  Apr.  15,  1905,  731-735. 
Babcock  (480,  549).    "Annals  of  Surgery,"  xlvi,  No.  5,  686. 
Bablee,  E.  R.  (329,  593,  965,  1015).    "The  Significance  of  Sudden 

Severe  Abdominal  Pain."     New  York  Med.  Jour.,  Aug.  5,  1905, 

Ixxxii,  276-320. 
.     "Significance  of  Sudden  Severe  Abdominal  Pain  in  the  Right 

Inguinal  Region."     Quart.   Bull.   ^led.   Dep.,  Wash.   Univ.,   St. 

Louis,  1904-1905,  iv,  No.  1,  41-51. 
Bach,  H.     "Zur  Aetiologie  der  Intercostalneuralgie."     Med.  Klin., 

Berlin,  1908-1909,  1475. 


BIBLIOGRAPHY  807 

Baerensprung,  vox.  "Die  Giirtelkrankheit."  Annalen  d.  Charite 
Krankenh.,  Band  x,  Heft  2   (1861),  40. 

Baerwinkel^  F.  "Die  Bedeutung  der  centripetalen  Irridiation  bei 
schmerzhaften  Affectioneu  der  Xerveustamme."  Deutsches 
Arehiv.  f.  kliu.  Med.,  Leipzig,  1875,  xvi,  186-199. 

Bailey  (544).  "Anesthesia  in  Spinal  Cord  Lesions."  Jour.  Ment. 
and  jSierv.  Diseases,  April,  1910.    Ab.,  J.  A.  M.  A.,  liv,  20,  165. 

Bailey^  P.  "The  Eelationship  of  Trauma  to  Organic  Disease  of  the 
Cord.  Two  Cases  of  Cord  Tumors."  Jour.  Ment.  and  Xerv. 
Dis.,  N.  Y.,  1908,  xxxv,  324-329. 

Bains.     "Abatement  of  Some  or  All  of  the  Vital  Functions." 

Baishixger  (601).  "Sciatica."  Med.  Record,  X.  Y.,  1908,  Ixxxiii, 
683-686. 

Barker  (254).  "A  Case  of  Circumscribed  Unilateral  and  Experi- 
mental Sensory  Paralysis."     Jour.  Exp.  Med.,  Apr.  2,  1896. 

Barlow,  Lazarus  (571).  "Pathologic  Physiology."  1st  ed.,  Lon- 
don, 478. 

Barnard  (227).  "The  Simulation  of  Acute  Peritonitis  by  Pleuro- 
pneumonic  Diseases."     Lancet,  clxiii,  Aug.  2,  1902,  280. 

Basch,  vox,  and  Hofmaxx  (379).  "LTntersuchuugen  iiber  die  In- 
nervation des  Uterus  und  seiner  Gefiisse."  Wiener  med.  Jahr- 
biicher,  1877.    Quoted  by  Gaskill  Ry,  195,  27. 

Bassler,  Axthony.  "Gastric  Ulcer,  Acute."  J.  A.  M.  A.,  Ivii,  4, 
282-283. 

Baumgarten,  a.  (944).  "Ueber  den  Schmerz."  Centralblatt  f.  d. 
Kneipp  Heilverf.  Worishofen,  1906,  xiii,  140-147. 

Bayliss,  W.  M.  (382),  and  Starling,  Ernest  H.  "Xerves  of  the 
Portal  Vein."     Jour.  Phys.,  xvii,  1894-1895,  125. 

(895),  .     "The  Movements  and  Innervation  of  the  Small 

Intestine."     Jour.  Phys.,  1900-1901,  xxvi. 

Beal,  F.  E.  (824).  Am.  Med.  Jour.,  1908,  Y^ear  Book  Series,  1909, 
xi,  338. 

Beatty,  W.  "Remarks  on  the  Causation  of  Pain  Referred  to  the 
Left  Side  and  of  Pain  in  the  Epigastric  Region."  Jour.  Med. 
Sci.,  Dublin,  1887,  Ixxxiii,  Xo.  2,  74-83. 

Bechterew,  von  (919).  "Die  Funktionen  der  Xervencentrale." 
Vorlag  von  Gustav  Fischer,  Jena,  1908,  i,  417. 

.     "LTeber  die  Hervorrufung  von   Schmerzen  bei  Ischias  durch 

Hyperexten^ion  der  Extremitiit  und  iiber  die  L'nfahigkeit  beide 
Beine  zu  strecken."  Xeurolog.  Centralblatt,  Leipzig,  1907,  xxvi, 
1107-1110. 

.  (443),     'Die  Leitungsbahnen,"'  1901. 


808  BIBLIOGRAPHY 

Bechterew,  von    (419).     "Die  sensiblen  Bahnen  in  Eiickeumarke. 

Nach  den  Untersuchungen  von  Dr.  F.  Holzinger."     Neurolog. 

Centralblatt,  1894,  xiii,  643. 
Becker,  H.    "De  doloribus."    Halae,  Magdeburg,  1720. 
Beevor.    "Case  of  Syphilitic  Tumors  of  the  Spinal  Cord  with  Symp- 
toms  Simulating   Syringomyelia."     Clinical    Society   Transact.. 

xxvii,  1893. 
Bennett,  Sir  William  H,   (240,  750).     "Some  Aspects  of  Appen- 
dicitis."    Lancet,  1907,  ii,  1005,  1055. 

.(367,736).    "Pain  in  the  Groin."    Lancet,  Feb.  2,  1907,  269. 

.   (475).     "A  Post-graduate  Lecture  on  Some  Clinical  Aspects 

of  Pain,  Especially  in  Reference  to  Its  Spontaneous  Disappear- 
ance."    British  Med.  Jour.,  July  4,  1908,  ii,  1-4. 
.    (196).     "A   Post-graduate    Lecture    Concerning    Pain    in   the 

Groin."     British  Med.  Jour.,  July  4,  1908,  ii,  1-4. 
Bergmark,   G.      "Cerebral   Monoplegia,   with    Special   Reference  to 

Sensation  and  to  Spastic  Phenomena."    Brain,  1909,  xxxii,  342. 
Bergstresser,  E.     "The  Nature  of  Physical  Pain."    Western  Dent. 

Jour.,  Kansas  City,  1896,  x,  481-486. 
Bernhardt    (460).      "Erkrankungen    der   peripherischen   Nerven," 

2te  Auflage,  Teil  i,  106. 
Bernicke.     "L'eber  appendizitische   Symptome  bei  Lobar  Pneumo- 

nien."    Med.  Klin.,  1909,  No.  7. 
Bernstein,  A.  H.  (833).    "Reflex  Pains."    Internat.  Jour.  Surgery, 

N.  Y.,  1906,  xix,  252. 
Bettman,  T.  W.     "Epigastric  Pain."     Cleveland  Med.  Jour.,  1901, 

vi,  321-324. 
Beuttenmuller,   H.     "Ueber  den   Zusammenhang  zwischen   Blut- 

druck  und  Schmerzempfindliclikeit."     Miinchen,  1903. 
Bevan  (704).    "Kidney  and  Ureteral  Stone."    J.  A.  M.  A.,  liv,  No. 

9,  665. 
Bevilacqua,  p.  G.     "II  sintomo  dolore  quale  causa  di  errore  diag- 

nostico."     L'Abruzzosan,  Chieti,  1904,  1,  9,  11,  17. 
Bier,  August   (331).     "Die  Entstehung  des  Kollateralkreislaufes." 

Virchow's  Archiv,  cxlvii,  1897;  cxlviii,  1898. 
Biernacki,    E.      "Beitrage    zur    Lehre    von    central    entstehenden 

Schmerzen    und    Hyperaesthesien."      Deutsche    med.    Wochen., 

1893,  52. 
.     "Ueber  Drucklahmung  der   Sensibilitat."     Gazeta   Lekarska, 

1892,  Nos.   45,  46;  Ref.   in  Neurolog.   Centralblatt,   1893,  xii, 

369. 
BixcH,   M.    E.      "Pain,   Intercostal,   as   a    Sign   of    Cholelithiasis." 


BIBLIOGRAPHY  809 

Archiv.  des  Maladies  de  I'App.  Digestive,  Paris,  March  5,  No.  3. 

Ab.,  in  J.  A.  M.  A.,  July  8,  1911,  171. 
BiNSWANGER.     "Hysterie."   Nothnagel's  "Specieller  Pathologie  imd 

Therapie." 
Bishop,  E.  Stanmore  (816).    "On  Biliary  Calculi."     Lancet,  Mar. 

24,  190G,  817-822. 

(229).  "Some  Points  in  Surgical  Abdominal  Diseases."  Lan- 
cet, Sept.  12,  1903,  740-744. 

.    "Treatment  of  Vesical  Calculus." 

(814).     "Tuberculosis."     Brit.  Med.  Jour.,  Mar.  23,  1907. 

BiSTRENiN,  I.  M.     "The  Path  of  Vasodilator  Fibers  of  the  Sciatic 

Nerve."  Nevr.  Vertnik,  Kazan,  1905-1906,  xiii.  No.  1,  1-89, 
diag.  2. 

BiTTOLE,  A.  "Stabilire  se  il  dolor  fisico  da  qualunque  causa  prodotto 
debta  considerasi  uno  stimolo."  Giorn.  d.  Soc.  med.  chir.  di 
Parma,  1810,  viii,  3-17. 

Blair,  V.  F.  (615).  "Trifacial  Neuralgia."  J.  A.  M.  A.,  Feb.  4, 
1911,  Ivi,  No.  5. 

Bland,  Sutton  J.  "Eight-sided  Abdominal  Pain  in  Women."  Prac- 
titioner, June,  1911,  Abstract  in  J.  A.  M.  A.,  Ivii,  No.  4, 
343. 

Bliss,  M.  A.  "Circumscribed  Serous  Spinal  Meningitis."  Inter- 
state Med.  Jour.,  St.  Louis,  1909,  xvi,  338. 

Blix.  Article  in  which  cold  spots  were  defined  in  the  skin.  Zeit- 
schrift  f.  Biologic,  1885,  xxi,  152. 

.  "Experimentielle  Beitrage  zur  Losung."  Zeitschrift  f.  Biol- 
ogic, 1884,  XX,  149;  1885,  xxi,  143. 

.     "Ueber    die   Hemisection    des   Riickenmarkes   bei    Hunden." 

Centralblatt  f.  Physiologie,  1895,  vii,  531. 

Bloch,  R.  "Dionin  als  schmerzstillendes  Mittel  in  der  Praxis." 
Therap.  Monatshefte.  Berlin,  1899,  xiii,  418-421. 

Bloodgood^  Jos.  C.    "Abdominal  Pain."    International  Clinics,  17th, 

1907,  i,  277. 

Bloomfield,  M.  "On  the  Hj^peresthetic  Areas  (Head's  Zones)  in 
Visceral  Disease."     Jour.  Nerv.  and  Ment.  Dis.,  Lancaster,  Pa., 

1908,  XXXV,  576-578. 

BocKHEiM.  "Einige  Bemerkungen  liber  das  Wesen  und  die  Bedeu- 
tung  des  Schmerzes."  Allg.  Med.  Centr.  Zeitung,  Berlin,  1849, 
xviii,  41-44. 

BoLDT  (911).  "The  Diagnosis  of  Extra-uterine  Pregnancy."  Am. 
Jour.  Obst.,  1908,  435. 

Bonnet,  S.  (364).    "Acute  and  Chronic  Appendicular  Pains;  Medi- 


810  BIBLIOGRAPHY 

cal  and   Surgical   Treatment.     A  Criticising  Essay."     Lancet, 

May  25,  1907,  1425. 
BoNNF.Y,  V.     "Abdoraino-pelvic  Pain  in  Women  Without  Physical 

Signs  of  Disease."    Practitioner,  London,  Aug.,  1911,  153.    Ab. 

in  J.  A.  M.  A.,  Sept.  2,  1911,  Ivii,  10,  851. 
BoRDET  (388).     "Le  traitement  electrique  des  douleurs  de  la  region 

sacrolombaire."  Bull.  off.  de  la  societe  frangaise,  1906,  xiv,  18-25, 

36-43. 
BoERi,  L.     "Sul  valore  del  segno  del   Mannkopff  per  la  diagnosi 

obiettiva  della  dolorabilita."     Riv.  di  diritto  e  giur.  s.  infortuni 

d.  lavoro,  Modena,  1902,  iv,  62-66. 
Bos,  C.     "Du  plaisir  de  la  douleur."     Eev.  phil.,  Paris,  1902,  liv, 

60-74. 
BoscHi,  H.     "Tardy  Gastric  Pains  from  Spasm  of  the  Pylorus  in 

Winter  with  Chronic  Gastric  Ulcer."     Archiv.  des  Maladies  de 

FApp.  Digestif,  Paris,  June,  1911.    Ab.  in  J.  A.  M.  A.,  Aug.  19, 

1911,  Ivii,  8,  689. 
BowLBY,  A.     "Pain,  Its  Importance  in  Diagnosis  and  Its  Tendency 

to  Mislead."     Clin.  Jour.,  London,  1903-04,  xxiii,  289-296. 
BOYCE   (437).     Phil.  Trans.  Eoyal  Soc,  1897. 
BoYD^  M.  Stanley   (303).     "Discussion  on  the   So-called  Ovarian 

Pain,  Its   Causes  and   Treatment."     British  Med.  Jour.,   1904, 

1060. 
Bradford  (75).    "Ulcer  of  the  Stomach.     Proposed  Surgical  Treat- 
ment."    Trans.  Am.  Assoc,  1892,  x,  9219. 
Bradford,  J.  R.   (217).     "Organic  Disease  Without  Obvious  Symp- 
toms."    Lancet,  Apr.  4,  1903,  941. 
Bramwell,  B.    (890).     "Causation   of   Angina   Pectoris."     British 

Med.  Jour.,  Jan.  15,  1910. 
Brancpii  (504).  "Psychiatry." 
Brazy   (727).     "Tuberculosis  of  the  Kidney."     Quoted  by  Thomas 

R.  Brown.     Osier's  "System  of  Medicine,"  285. 
Bremssen,  0.     "Heilung  der  Ischias."     Zeitschr.  f.  Phys.  und  diat. 

Therapie,  Leipzig,  1907-08,  xi,   678,  681. 
Brentan.     "Psychologic."     1874,  ch.  viii. 

Brewer,  G.  E.  (113).     "Some  Errors  in  Diagnosing  Conditions  Re- 
sembling Appendicitis."     Annals  of  Surgery,  May,  1901. 
Brissaud.     "La  douleur  a  volonte."     Bull,  med.,  Paris,  1903,  xvii, 

721. 
.     "Les  douleurs  d'habitude."    Cong.  d.  med.  alienistes  et  neurol. 

de  France,  Brux.,   1903,  xiii.  No.  2,  251-263.     Progres  Med., 

Paris,  1901,  xix,  3,  5,  17-22. 


BIBLIOGRAPHY  811 

Brizio,  G.  V.  (337).  "Algometio."  Giorn.  Med.  di  Torino,  1896, 
xlvii,  661-664.  Giorn.  d.  r.  Acad,  di  Med.  di  Torino,  1896,  3r., 
xliv,  405-408. 

Brodie  (169).     "Local  Nervous  Affections."     1837,  12. 

Brooks  (781).    Medical  Press  and  Circular,  London,  Apr.  24,  1907. 

(245).     "On  the  Distribution  of  the  Cutaneous  Nerves  on  the 

Dorsum  of  the  Human  Hand.''     Intern.  Monatsschrift  f.  Anat. 
u.  Physiologic,  1888,  v. 

(93).     "Visceral    Arteriosclerosis."      Am.    Jour.    Med.,    May, 

1906,  i,  778. 

Brophy^  T.  W.  "The  Peripheral  Courses  of  Trifacial  Neuralgia  and 
Its  Surgical  Treatment."  Dental  Brief,  Phil.,  1909,  xiv,  525-533. 

Brothers.     Am.  Jour.  Obst.,  lix,  675. 

Browx   (808).     Osier's  "System  of  Medicine,"  v,  612. 

Brown,  Langdon  W.  (583,  780,  799).  "Physiologic  Principles  in 
Treatment."     1st  ed.,  79,  286. 

Brown,  Lawrason.    Osiers  "System  of  Medicine."    1st  ed.,  viii,  281. 

Brown-Sequard  (408).  "Lectures  on  the  Physiology  and  Pathol- 
ogy of  the  Nervous  System."  Lancet,  1868,  ii,  593,  659,  755, 
821. 

.     "Zur    Pathologic    der    chronischen    atrophischen    Spinallah- 

mung."     Archiv  f.  Psychiatric,  1892,  xxiv,  758. 

.     "Eecherches  sur  la  transmission  des  impressions  de  tact,  etc., 

dans  la  moelle  epiniere."     Jour,  de  Physiologic,  1863,  vi,   124. 

Bruce,  Williaji  J.  (502).  "Sciatica.  An  Inquiry  as  to  Its  Real 
Nature  and  Eational  Treatment  Founded  on  the  Observations 
of  Upwards  of  400  Cases."     Lancet,   Aug.   22,   1903,   511-514. 

.     "Referred  Pains  Mostly  Gouty  in  Their  Origin."     Scottish 

Med.  and  Surg.  Jour.,  Edinburgh,  1904,  xiv,  297-304. 

.    "The  Relation  Between  Sciatica  and  Disease  of  the  Hip-Joint." 

Practitioner,  London,  1908,  Ixxx,  475-483,  6  pi. 

Brunton,  Sir  Lauder  (516).  "Alkalinity  of  the  Blood  as  a  Cause 
of  Pain."    British  Med.  Jour.,  Oct.  18,  1902,  1244. 

(585).     "Disorders   of   Digestion."     Ed.   1886,   108-109. 

.     "Principles  of  Pharmacology.     Eighty  Effects  of  a  Mustard 

Plaster." 

(11,  524).     "Some  Forms  of  Abdominal  Pain."     Intern.  Clin., 

Phil.,  1898,  iii,  111-120. 

(39,  192,  484).     "On  the  Use  of  Alkalies  in  Relieving  Pain." 

British  Med.  Jour.,  Oct.  18,  1902,  ii,  1244. 

(38).     "On  the  Use  of  Codein  to  Relieve  Pain  in  Abdominal 

Disease."     British  Med.  Jour.,  1889,  i,  1213, 


812  BIBLIOGRAPHY 

Bryant,  Wm.  Cullen  (895).  "The  Symptomatology'  of  Prostatitis." 
J.  A.  M.  A.,  Mar.  6,  1909,  lii,  754-757. 

Bryson  (708).  "A  Clinical  Study  of  Myocarditis."  Boston  Med. 
and  Surg.  Jour.,  cxliii,  No.  14,  348. 

BucH,  Max  (171).  "Das  arteriosklerotische  Leibweh."  St.  Peters- 
burger  med.  Woch.,  1904,  xxix.  No.  27,  290-299.  Am.  Jour. 
Med.  Sc,  1905,  No.  1,  532. 

(383).      "Die    Sensibilitatsverhaltnisse    des    Sympathicus    und 

Vagus."     Archiv  f.  Anat.  und  Physiol.,  1901,  197. 

(342).     "Sympaticus  neuralgier  som  symptom  af  ett  patalog. 

irritations  stillstand  hos  sympaticus."     Finsk  lakaresathkaprts 
handlinger,  1901,  iii,  334-255. 

Buckley,  Chas.  W.  (606).  "Brachial  Neuritis."  Clinical  Excerpts, 
xiv,  1908,  No.  889. 

Budge  (466).     "Lehrbuch  der  Physiologie."     8te  Auflage,  1862. 

BuFORD,  G.  G.  "Lesions  of  the  Spinal  Cord,  with  Eeport  of  Cases." 
Memphis  Med.  Monthly,  1909,  xxix,  462-467. 

BuLQUOY  (78).  "Differential  Diagnosis  Between  Duodenal  and  Gas- 
tric Ulcer."     Arch.  Gen.  de  Med.,  1887,  i,  398,  526,  691. 

BuMPUs,  W.  H.  "Autobiographical  Report  of  a  Case  of  Trigeminal 
Neuralgia."  Southern  Practitioner,  Nashville,  1909,  xxxi,  107- 
123. 

BuRDiCK  (167).    "X-ray  Pain."    Book  on  X-ray. 

BuRKHARDT.  "Die  physiologische  Diagnostik  der  Nervenkrank- 
heiten."     Leipzig,  1875,  579  ff. 

BuRNARD  (867).  "Zusammenhang  der  Sensibilitiit  und  Irritabilitat 
des  Uterus."  "Schmidtischen  Handbuch"  (Neuman),  1852, 
No.  73. 

Burns,  Alan  (84).  "Pain  in  Arterial  Disease."  Med.  Chronicle, 
1905. 

BuRRH,  L.  E.  (808).  "The  Significance  of  Abdominal  Pain."  South- 
ern Med.  and  Surg.,  Chattanooga,  1907,  vii,  292-293. 

BuTTERWORTH,  W.  W.  "The  Clinical  Significance  of  Growing  Pains 
in  Children."  New  Orleans  Med.  and  Surg.  Jour.,  1908-09,  Ixi, 
345-348.     Discussion,  380-381. 

Buzzard,  E.  F.  (256).    "Myasthenia  Gravis."    Brain,  xxviii,  438-484. 

(526,  613).     "Nerve  Roots."     Brain,  xxv,  290,  299. 

Byers,  J.  W.  (312).  "Discussion  on  the  So-called  Ovarian  Pain, 
Its  Causes  and  Treatment."     British  Med.  Jour.,  1904,  1062. 

Cain,  John  S.  (115).  "Pain  as  a  Diagnostic  Factor."  Nashville 
Jour.  Med.  and  Surg.,  June,  1903,  xciii,  243-250. 

Calo,  a.     "Su  alcune  modificazione  della  sensibilita  durante  lo  state 


BIBLIOGRAPHY  813 

di  dolore,  contributo  all'  applicazione  dell'  eccitamento  elettro 
faradico  all'  esame  del  dolore  negli  infortunati."  Ramazzini, 
Firenze,  1908,  i,  85-98. 

Camp,  C.  D.  "The  Course  of  Sensory  Impulses  in  the  Spinal  Cord." 
Jour.  Nerv.  and  Ment.  Dis.,  1909,  xxxvi,  77-96. 

Campanella,  G.  "Le  diagnosi  del  dolore."  Gazz.  di  osp.,  Milano, 
1904,  xxi,   2020. 

Campbell,  A.  W.  (420).  "Histological  Studies  on  the  Localization 
of  Cerebral  Functions."    Camb.,  1905. 

Campbell,  John  (301).  "Discussions  on  the  So-called  Ovarian 
Pain,  Its  Causes  and  Treatment."  British  Med.  Jour.,  1904, 
1060. 

Campbell,  J.  A.  E.  "Pain  and  Its  Significance  in  Diagnosis."  Mon- 
treal Med.  Jour.,  1902,  xxxi,  471-478. 

Campbell,  Thompson  H.  (289).  "Causation  and  Treatment  of 
Headaches."      Practitioner,    1906,    15-19. 

Cannon,  W.  B.,  and  A.  L.  Washburn.  "Cause  of  Hunger  Sensa- 
tion."    Am.  Jour.  Phys.,  March,  1912,  xxix,  5,  455. 

Capps,  Jos.  A.  "Experimental  Study  of  Pain  Sense  in  Pleural  Mem- 
branes." Ab.  in  J.  A.  M.  A.,  Ivi,  No.  24,  1849.  Archiv.  of 
Intern.  Med.,  Dec.  15,  1911,  No.  6.  Ab.  in  Lancet,  Jan.  13, 
1912,  109. 

.     "Four  Cases  of  Malaria  Associated  with  Acute   Abdominal 

Pain."     J.  A.  M.  A.,  Aug.  4,  1900,  287. 

Carleton,  H.  G.  (123).  "External  Use  of  Adrenalin  in  Neuralgia, 
Neuritis  and  Eeflex  or  Eeferred  Pain."  Therapeutic  Gazette, 
May,  1907,  293. 

Carriere,  G.  (408).  "Des  douleurs  abdominales  en  clinique  infan- 
tile." Nord  med.,. Lille,  1904,  X,  169-174.  Annales  de  la  policlin. 
de  Paris,  1905,  xv,  28-42. 

Castex,  G.   (442,  699).     "La  douleur  physique."     Paris,  1905,  8°. 

.     "La  douleur  physique.     Etude  de  psychologie  experimentale. 

Preface  par  G.  Sorel."     Paris,  1906,  G.  Jacques,  140,  8°. 

Cathelin  (715).     La  Monde  Medicale,  No.  294,  33. 

Cauthie  (807).  "Diseases  of  the  Liver,  Gall  Bladder  and  Gall 
Ducts."    Eolleston,  162. 

Cavazzini.  Archiv.  Italiano  di  Bologna  (cited  by  Baiken),  xvii, 
413. 

Cecikas,  J.  "Les  algies  abdominales."  Eev.  de  med.,  Paris,  Jan., 
1912,  xxxii,  No.  1. 

Championniere,  Lucas.  "La  douleur  au  point  de  vue  chirurgicai."' 
Eev.  sci.,  Paris,  1901,  xv,  225-235. 


814  BIBLIOGRAPHY 

Champneys  (317).  "On  the  Pain  in  Pelvic  Cancer  and  Its  Eelief  by 
Morphia,  Illustrated  by  Fifty  Cases."     Obst.  Jour.,  1880,  xxii. 

(909).     Obst.  Trans.,  xxii,  1880. 

Chapmian,  J.     "Observation  on  Dr.  C.  B.  Eadcliffe's  Theory  of  the 

Genesis  of  Pain."     Med.   Times  and  Gaz.,  London,   1871,   11, 

765;  1872,  1,  66. 
Charcot.    "De  la  dissociation  syringomyelique  et  sections  des  tronces 

nerveux."     Comptes  rendus  de  la  Societe  de  Biologie  de  Paris, 

i,  941. 
Charcot  et  Gombault.    "Un  cas  de  lesions  disseminees — des  centres 

nerveuse  observees  chez  une  femme  syphilitique."     Archives  de 

physiologie,  1873,  v,  143. 
Chauffard  (821).    "Cancer  of  the  Body  of  the  Pancreas."    Ab.  in 

British  Med.  Jour.,  Oct.  31,  1908,  1403. 
Chaveau.    Arch.  gen.  de  med.,  1900,  am.  77,  N.  S.  Ill,  66. 
Chernisse,  L.  (454).     "Les  appendicitis  fantomes  et  les  fausses  ap- 
pendicitis."    Semaine  medicale,  1910,  xxx.  No.  1,  1-12;  J.  A. 

M.  A.,  liv,  573. 
Chirotius.     "De  dolore  dialogus,  Theodorus,  Eudoxus,  Chrysippus, 

in  hoc;  prosperiores  cogitationes.     (Ect.)"     Parislio,  1669,  127- 

158. 
Chizh,  V.  F.    "Ischias."     (In  German.)     "Bol"  ("Pain").    Yuryev, 

1899.     Vopr.  filos  i.  psichol.,  Moskau,  1899,  x,  269-303.     "Der 

Schmerz."     Zeitschrift  f.  Psychol,  u.  Physiol,  d.  Sinnesorgane, 

Leipzig,  1901,  xxvi,  14-32. 
Church  and  Peterson  (506).    "Mental  and  Nervous  Diseases."  369. 
Claiborne.    "A  Case  of  Subjective  Pain."    Psychological  Eeview,  ii, 

6,  599. 
Clairmont.       "Zur     Kenntnis     der    hyperalgetischen     Zone    nach 

Schadelverletzungen."    Mitteil  a.  d.  Grenzgeb.  d.  Med.  u.  Chir., 

xix,  1909. 
Clark,  J.  J.  (366,  404).     "The  Prevention  of  Pain  After  Surgical 

Operations."    Clin.  Jour.,  London,  Mar.  6,  1907,  xxiv,  331-335. 

(258,  350).    "Unsettled  Questions  in  Abdominal  Surgery."  Am. 

Jour,  of  Obst.,  May,  1904,  590. 

Clevenger,  S.  V.  (40,  326,  476,  621,  844).  "Pain  and  Its  Thera- 
peutics."   J.  A.  M.  A.,  1897,  xxviii,  5,  193-198,  661-671. 

Clinch,  Aldons  (524,  542).  "The  Area  of  Cutaneous  Distribution 
of  First  Sacral  and  Fifth  Lumbar  Nerves  as  Illustrated  by  Two 
Cases  of  Herpes  Zoster."     Brain,  1901,  xxiv,  643. 

Clouston,  T.  S.  (520).  "The  Relationship  of  Bodily  and  Mental 
Pain."    British  Med.  Jour.,  London,  1886,  ii,  319-323, 


BIBLIOGRAPHY  815 

Cobb,  F.  (52,  375).  "Strange  Keason  for  Persistent  Abdominal 
Pain."     Boston  Med.  and  Surg.  Jour.,  July  4,  1907,  clvii,  18. 

CoELHO,  Sabino.  "A  dor  em  gynecologia."  Med.  Contemp.,  Lisb., 
1903,  xxi,  162. 

•CoGGESHALL,  F.,  and  MacCoy,  W.  E.  "Headache  as  a  Symptom  of 
Local  Disorders."     J.  A.  M.  A.,  Chicago,  1908,  i,  15-19. 

Cole  (593).  "Gonococci  Infections."  Osier s  "System  of  Medicine," 
1st  ed.,  iii,  113. 

Collier,  James  (393).  "Transverse  Lesion  of  the  Spinal  Cord  in 
Man."     Brain,  xxvii,  38-63. 

Collier  and  Buzzard  (434).  "The  Degeneration  Resulting  from 
Lesions  of  the  Posterior  Eoots  and  from  Transverse  Lesions  of 
the  Spinal  Cord  in  Man."    Brain,  1903,  xxiv,  559. 

CoLLiGAEis,  G.  "Die  segmentare  Abgrenzung  der  Anesthesia." 
Monatsschrift  f.  Psychiat.  u.  Neurol.,  Berlin,  1909,  xxv,  477-479. 

CoLucci,  C.  (240).  "Le  impronte  vasculari  del  dolore  fisico  per  la 
psicologia  sperimentale  e  per  la  semeiotica  della  simulazione." 
Med.  Italiana,  Napoli,  1906,  iv,  7-9.  Ann.  di  Neurot.,  Napoli, 
1905,  xxiii,  323-370. 

Cooper,  C.  M.  (801).  "Backache."  Cal.  State  Jour,  of  Med.,  1909, 
vii,  221-242. 

Coote,  C.  "Inframammary  Pain."  Med.  Times  and  Gaz.,  London, 
1858,  xvii,  47-49. 

CoRBUS,  B.  C.  "Cause  of  Immediate  Pain  and  Abscess  Following  the 
Administration  of  Salvarsan  by  the  Alkaline  Method."  J.  A. 
M.  A.,  Ivi,  No.  17,  1262. 

Corning,  J.  L.  (6,  208).  "Pain,  Its  Nature,  Diagnostic  Significance 
and  Treatment."  Tr.  Med.,  N.  Y.,  1892,  337-350;  N.  Y.  Med. 
Jour.,  1892,  Iv,  428-433. 

(48).  "Pain  in  Its  Neuro-pathological,  Diagnostic,  Medico- 
legal and  Neuro-therapeutic  Relations."  Philadelphia,  1894  (J. 
B.  Lippincott  and  Co.). 

Coulter,  F.  E.  "Some  Nervous  Symptoms  Depending  on  Arterio- 
sclerosis."   Western  Med.  Rev.,  Omaha,  1907,  xii,  456-464. 

CozzoLiNO  (111,  492).  "Dolore  ectopico  appendicolare."  Gazzetta 
degli  Ospidale  e  delle  Cliniche,  1903,  v,  45. 

Craig,  D.  H.  (910).  N.  Y.  Med.  Jour.,  1905,  quoted  by  Keely, 
"Medical  Gynecology,"  435. 

Crile,  G.  N.  (521).  "Phylogenetic  Association  in  Relation  to  Cer- 
tain Medical  Problems."  Address  before  Mass.  Gen.  Hosp.,  64th 
Anniversary  of  Ether  Day,  Oct.  15,  1910.  Boston  Med.  and 
Surg.  Jour.,  1910,  No.   24. 


816  BIBLIOGRAPHY 

Ci?OMMENiCK.  "These  sur  la  douleur."  Ann.  soc.  de  sei.  nat.  de 
Bruges,  1846,  i,  160-181. 

Crompton,  D.  "Courage  or  Insensibilit}'  to  Pain  During  Double 
Amputation  of  the  Legs  Without  Chloroform?"  Guy's  Hospi- 
tal Eeports,  London,  1887,  35,  xxi,  x,  143. 

Crosby,  A.  B.  "The  Significance  of  Pain."  Tr.  N.  Hamp.  Med. 
Soc,  Concord,  1865,  18-37. 

Crossen,  H.  S.  (913).    J.  A.  M.  A.,  liv,  No.  7,  519. 

CuMSTON,  C.  G.  (12,  580,  797).  "Abdominal  Pain  from  Adhesions." 
Albany  Med.  Annals,  1905,  xxvi,  310-316. 

(172,  446).  "Pain  as  a  Symptom  in  Urinary  Disease."  Vir- 
ginia Medical  Semi-month.,  Eichmond,  Apr.  7,  1905,  x,  5-11. 

(535,   637).     "Significance  of  Sudden   Severe   Pain  in   Eight 

Inguinal  Eegion."     Quart.  Bull.,  Med.  Dep.,  Wash.  Univ.,  St. 
Louis,  1904-05,  iv,  No.  1,  41-45. 

Cunningham,  E.  H.    "A  Case  of  Dissociated  Sensory  Disturbances." 

Jour.    Nervous    and   Mental    Dis.,    Lancaster,    Pa.,    1909,   xiii, 

226-231. 
CuRSHMANN,  T.  (54,  185,  567,  1169).     "Schmerz  und  Blutdruck." 

Miinch.   med.    Woch.,    Oct.    15,    1907,   liv,   No.    42,   2074-2077. 

"Differential  Value  of   Fluctuation  in   Blood   Pressure   During 

Pain."    J.  A.  M.  A.,  Nov.  23,  1907,  xlix,  1813. 
CuRTiN    (891).     "Angina  Pectoris."     British  Med.  Jour.,  Apr.  14, 

1905,  858. 
Curtis,  J.  B.    (168).     "Pododynia,   Its   Causes  and   Significance." 

Boston  Med.  and  Surg.  Jour.,  Apr.  7,  1881,  316-318. 
Gushing  (94).    Annals  of  Surgery,  1904,  cxxx.  Part  934, 

(776,  777).    Keen's  "System  of  Surgery,"  iii,  18-19,  104. 

Gushing,  Harvey,  and  Thomas,  H.  M.   (880).     "Location  of  the 

Sensory  Areas."    J.  A.  M.  A.,  Mar.  14,  1908,  1,  847-856. 
Da  Costa  (95,  817).    "Medical  Diagnosis,  Pain,  etc.,"  483. 
Daland,   Judson.     "Diagnosis  of   Pain   in  the  Upper   Abdomen," 

J.  A.  M.  A.,  Apr.  6,  1912,  Iviii,  14,  1002. 
Dale,  W.     "On  Pain  and  Some  of  the  Eemedies  for  Its  Eelief." 

Lancet,  London,  1871,  i,  641,  679,  739,  816. 
Dana,  G.  L.    Jour,  of  Nerv.  and  Ment.  Dis.,  April,  1894.    Cited  by 

Witmer. 

.     "A  Clinical  Study  of  Neuralgia."     Published  1888. 

.     "Erythromelalgia."  "Textbook  Nervous  Diseases,"  1908  (Wm. 

Wood  and  Co.),  229. 
.     "The  Interpretation  of  Pain  and  the  Dysesthesias."     J.   A. 

M.  A.,  Ivi,  No.  11,  787. 


BIBLIOGRAPHY  817 

Dana,  C.  L.    "Morton's  Neuralgia."    "Textbook  Nervous  Diseases/' 

1908  (Wm.  Wood  and  Co.).,  230. 
— ■ — .     "Pain  sense,  testing  the,"  59 ;  "Pains,  cervicooccipital,"  212 ; 

"Pain,  finger,"  219;  "Pain,  forearm,"  219;  "Pain,  heart,  arm," 

219;   "Pain   Causing   Locomotor  Ataxia,"   306;   "Pain,   lumbo- 

abdominal,"  223;  "Pain,  neck,"  214;  "Pain,  side,"  221;  "Pain 

spot  in  locomotor  ataxia,"  307 ;  "Pain,  transferred  diagram  of 

location  of,"  174;  "Pain  paresthesias,"  169.    "Textbook  Nervous 

Diseases,"  1908  (Wm.  Wood  and  Co.).       » 
.     "Sciatica."     "Textbook  Nervous  Diseases,"  1908   (Wm.  Wood 

and  Co.),  225-230. 
Daenall,  W.  E.     "Eemote  Pain  Following  Abdominal  Operations." 

Jour.  Med.  Soc,  New  Jersey,  1908-09,  v,  170-172. 
Davenport.      "Chronische    Kopfschmerzen    bei    Erkrankungen    der 

Becken-Organe."    J.  A.  M.  A.,  1908,  No.  1. 
Dawson,  B.  E.     "The  Language  of  Pain."     Kansas  City  Med.  Eec- 

ord,  1902,  xix,  217-219. 
Dean,  L.  W.  (175).     "Supraorbital  Pains."     Iowa  Med.  Jour.,  May 

15,  1905. 
Deaver,  J.  B.   (825).     "The  Diagnosis  and  Surgical  Treatment  of 

Acute  Pancreatitis."     Am.   Jour.   Med.   Sci.,   Dec,   1909,   837. 

(13,  160,  234,  535,  744,  764,  837).  "The  Diagnosis  and  Treat- 
ment of  Abdominal  Pain."  J.  A.  M.  A.,  May  13,  1905;  xliv, 
1523-1528. 

(820).     "Gallstone  Disease."     Amer.  Jour.  Med.   Sci.,  Nov., 

1908. 

De  Bey.  "Ueber  Schmerzwanderung."  Med.  Corr.  Blatt  d.  rhein. 
u.  westfal.  Aerzte,  Bonn,  1843,  ii,  359-369. 

Debove  and  LetuLle  (384).     Arch.  gen.  de  med.,  1880,  i,  275. 

Dejerine,  J.  "Contribution  a  I'etude  des  localisations  matrices 
spinales  dans  un  cas  de  desarticulation  scapuls  humeral  remon- 
tant a  I'enfance."  Rev.  neuroL,  Paris,  1909,  xvii,  593-660,  inch 
3  pi. 

and  Truel,  J.    "Un  cas  de  radiculite  lumbo-sacree  a,  meningo- 

coque."    Eev.  neurol.,  Paris,  1909,  xvii,  635-638. 

Delperier.  "Sur  la  douleur."  Bull.  soc.  centr.  de  med.  vet.,  Paris, 
1904,  Iviii,  208-211. 

Depage  (629,  761).  "Painful  Displacements  of  the  Ribs."  British 
Med.  Jour.,  Oct.  3,  1908. 

"De  Partibus,  Sensibilibus  et  Irritabilibus."  (758.)     Gottingen,  1752. 

Dercum,  C.  T.  (150).  "Nervous  Disorders  in  Women  Simulating 
Pelvic  Disease."     J.  A.  M.  A.,  Mar.  13,  1909,  848-853. 


818  BIBLIOGRAPHY 

Dercum,  C.  T.  (347).     "On  the  Eelation  of  the  Great  Neuroses  to 

Pelvic  Disease/'    Am.  Jour.  Gyn.  and  Obst.,  xiii,  129. 
Desplats   (358).     "Note  sur  les  injections  gazeuses  contre  la  dou- 

leur."     Jour,  de  sci.  med.  de  Lille,  1905,  i,  97-100. 
Dessoie.     "Ueber  den  Hautsinn."     Archiv  f.  Physiol.,  1892,  176. 
Dickson,  S.  H.     "An  Introductory  Lecture  on  Pain  and  Death." 

Charleston  Med.  Jour,  and  Eev.,  1860,  xv,  33-61. 
Diller,  Theo.   (65).     "Pain  as  the  Chief  or  Sole  Expression  of  a 

Psychic  State."     International  Clinics,  1908-18   Series,  ii,  86. 
DiSEN,  G.  F.  (598).    "Inflammation  of  the  Circumflex  ISTerve."    Med. 

Eecord,  N".  Y.,  1908,  Ixxxiv,  18. 
Donald,   Archibald    (1219),   and  Lickley,   J.   D.    (924).     "Ab- 
dominal Pain  in  Diseases  of  the  Pelvic  Organs."     Practitioner, 

London,  1906,  Ixxvii,  No.  2,  429-440. 
Donley.     "Keport  of  a  Case  of  Tumor  of  the  Spinal  Cord  and  of  a 

Case   of    Suppurative    Pachymeningitis   Externa."      Providence 

Med.  Jour.,  1908,  ix,  194-197. 
Donovan,  J.   (511a).     "Why  Do  Animals  Cry  in  Pain?"     Lancet, 

Jan.  27,  1906,  253. 
DoRAN     (320,    925),       "Painful     and    Tender     Incipient    Ovarian 

Tumors."     Jour.  Obst.  and  Gyn.  of  the  British  Empire,  May, 

1904. 
Double,  F.  J.    "Fragment  de  senecotipie  et  considerations  prodiqites 

sur  la  douleur."    Jour.  gen.  de  med.  chir.  et  pharm.,  Paris,  1805, 

xxiv,  353-368. 
Dowse  (588).    "Syphilis  of  the  Spinal  Cord."    Quoted  by  W.  Henry 

Alfred  Bobbins,  June,  1908,  xii.  No.  6,  246. 
Drenxan,  J.  G.    "Intermenstrual  Pain."    Med.  News,  N.  Y.,  1903, 

Ixxxii,  68. 
Dreshfield,  D.  Julius  (268).    "System  of  Medicine."    Allbutt  and 

Rolleston,  London,  iii,  464. 
Drien,  W.   C.    (773).     "Varieties  of  Brain  Tumors."     Meeting  of 

Philadelphia  Co.  Med.  Soc,  N.  Branch,  1908,  iii,  9. 
DucHEK.    Wiener  med.  Jahrbiicher,  1864. 
Duckworth,  Sir  D.  (604).     "Sciatica,  Its  Nature  and  Treatment." 

International  Clinics,  Philadelphia,  1908,  xvii,  3 ;  iii,  1-5. 
Duncan,  J.  Matthews  (262).     Med.  Times  and  Gazette,  Nov.  16, 

1878,  563. 
DuPLAix   (390).     "Contributions  a  I'etude  de  la  sclerose."     Paris, 

1883. 
DuPUY,  A.    "Essai  sur  la  douleur  envisagee  principalement  au  point 

de  vue  chirurgical."     Paris,  1901. 


BIBLIOGRAPHY  819 

DuTiL  and  Lamy   (388),     "Contribution  a  I'etude  de  I'arterite  ob- 

literante  progressive  et  des  nevrites  d'origine  vasculaire."     Arch. 

de  med.  exp.,  1893,  v,  102. 
Duval,  M.  and  Fromentil,  G.     "Sur  les  sympathets  douloureuses 

en  synalgies."     Compt.  med.  soc.  bull.,  Paris,  1881,  v,  4-6,  7,  8. 
Dydinski  (432).     "Ein  Beitrag  zum  Studium  des  Verlaufes  einiger 

Eiickenmarksstrange."'    Neurol.  Centralblatt,  1903,  898. 
Edes,  Eichard  E.  (202,  377).    "On  the  Method  of  Transmission  of 

the  Impulse  in  Medullated  Fibers."     Jour.  Physiol.,  1892,  xiii, 

431. 
Edge,  Frederick  (314).    "Discussion  on  the  So-called  Ovarian  Pain, 

Its  Causes  and  Treatment."     British  Med.,  1904,  1063. 
Edgeworth,  F.  H.   (196).     "On  a  Large-fibered  Sensory  Supply  of 

the  Thoracic  and  Abdominal  Viscera."     Jour.   Physiol.,   1892, 

xiii,  260. 
Edinger,  L.    Deutsche  Klinik,  vi,  1, 

(771).     "Diseases  of  the  Nervous  System."     Modern  Clinical 

Medicine. 

(439).     "Ueber  die  Fortsetzung  der  hinteren  Riickenmarkswur- 

zeln  zum  Gehirn."    Anat.  Anzeiger,  1889,  121. 

.     "Gibt   es   central   entstehende    Schmerzen?"     Deutsche   Zeit- 

schrift  f.  Zahnheilkunde,  1891,  i,  262-282;  Deutsche  Zeitschrift 

f.  Nervenheilkunde,  1891,  i,  262. 
,     "Ueber    den    heutigen    Stand    der    Lehre    vom    Schmerz." 

Deutsche  Monatsschrift  f.  Zahnheilkunde,  Leipzig,  1902,  xx,  575- 

579. 

(574).     "Zur  Lehre  vom  Schmerz."    Archiv  f.  Psychiatric,  Ber- 
lin, 1891,  xxiii,  600. 

(415,  421,  436).    "Vorlesungen  liber  den  Bau  der  nervosen  Zen- 

tralorgane."    Leipzig,  1904,  103,  120. 

Editorial  (831).     Annals  of  Surgery,  1908,  137. 

.     Deutsche  Zeitschrift  f.  Nervenheilkunde,  1892,  ii,  106. 

(479).     Glasgow  Med.  Jour.,  1898,  1. 

(191).     J.  A.  M.  A.,  xlix,  283. 

(500).     "The  Biologic  Analysis  of  General  Sensation."     J.  A. 

M.  A.,  lii,  22. 

' C.  W.  F.  (504).    "Is  This  a  Chill  on  the  Appendicitis?"    Guy's 

Hosp.  Gazette,  London,  1907,  xxi,  109. 
■ (292).     "The  Mechanism  of  Abdominal  Pain."     Lancet,  Aug. 

17,  1907,  465. 
.    "Muscular  Efficiency  and  Pain."    J.  A.  M.  A.,  Mar.  25.  1911, 

Ivi,  12,  898. 


820  BIBLIOGRAPHY 

Editorial  (497).  "The  Naturj  of  Sensation."  Review  in  Literary 
Digest,  Feb.  26,  1910,  389.*  Article  by  Prof.  E.  de  Cyon  in  Eev. 
sci.,  Jan.  8,  1910. 

C.  J.    "Observations  on  Chronic  Pain  After  Injuries  and  Some 

Corresponding  Strictures  on  the  Medical  Evidence  Given  in  an 
Action."    Glasgow  Med.  Jour.,  1831,  iv,  221-229. 

(228).     "Eeferred  Pain."    Lancet,  Sept.  12,  1903,  756. 

(8).     "A  Theory  of  Pain."    British  Med.,  1906,  i,  880. 

(452,  515).     "Toxic  Theory  of  Pain."     British  Med.  Jour., 

Apr.  14,  1906,  i,  880. 

Edwards,  Ar'^hur  E.     "Abdominal  Pain  and  Tenderness,  etc.,  in 

Thoracic  Diseases."  J.   A.   M.   A.,   June   17,   1911,   Ivi,    1784- 

85. 
EiCHHORST,  M.    (487,  553).     Article  on  nerve  lesions.     Mod.  Clin. 

Med.  Diseases  of  Nervous  System,  833. 
.     "Neuropathologische  Beobachtungen  (Hematomyelie)."    Cha- 

rite  Annalen,  1876,  i,  192. 
EiSENDRATii  (579,  794).    "Applied  Anatomy."    1st  ed.,  266. 

(452).     "Operative  Surgery.     Abdominal  Eeferred  Pain,"  276. 

(729,  796).     "Surgical  Diagnosis."     1st  ed.,  316,  335. 

Elliot,   E.    H.      "On    Some   Forms   of   Headache."      Indian   Med. 

Gazette,  Calcutta,  1907,  xlii,  409-411. 

Elmergreen,  E.    "Pain."    Milwaukee  Med.  Jour.,  1902,  x,  91-95. 

Eloy,  C.  "Douleur."  Diet,  encycl.  d.  sci.  med.,  Paris,  1884,  xxx, 
465-511. 

Elsberg  (833,  838).  "Eeferred  Pain  in  Appendicitis."  Annals 
of  Surgery. 

Engel,  F.  (133).  "Segmental  Diagnosis  of  Spinal  Cord  Lesions," 
Deutsche  med.  Woch.,  xxxvi,  11, 

Engelhardt,  E.  von  (381).  "Darmkatarrh  und  Darmneurose."  St. 
Petersburg,  med.  Woch.,  1895,  48.     (Eef.  from  Busch.) 

Engelhaupt,  J.  S.  "De  dolore  colico  et  iliaco."  Eolfinck  W.  Epi- 
tome meth.  cognosce,  Jena,  1655,  257,  276. 

Erben,  S.  "Diagnose  des  Kreuz  und  Eiickenschmerzes."  Med.  klin., 
Berlin,  December,  1911,  vii,  No.  51.  Ab,  in  J,  A.  M.  A.,  Jan. 
20,  1912,  Iviii,  No.  3,  233, 

.     "Differentialdiagnose  der  peripheren  Ischias."     Wiener  med, 

Woch.,  1909,  lix,  1993-1995. 

Erdmann,  J.  F.  (1,  155,  581,  798).  "Digestive  Disorders  and  Ab- 
dominal Pain."    Med.  Eecord,  N.  Y.,  1906,  Ixix,  93-95. 

Erlanger,  B.  "Zur  diagnose  des  Magenkarzinoms  mit  besondern 
Hinweis  auf  des  Schmerz  Symptom."     Archiv  fiir  Verdauungs 


BIBLIOGRAPHY  821 

Krankheiten,  Berlin,  December,  1910,  xvi,  No.  6,  728.     Ab,  in 

J.  A.  M.  A.,  Ivi,  4,  310. 
Erving,  Wiltrout  (775).     Clinical  Excerpts,  xv.  No.  3. 
EsHNER^  A.  A.     "A  Case  of  Hematomyelia  and  of  Syringomyelia." 

Arch.  Diag.,  N.  Y.,  1909,  ii,  71-73. 
EsTES,  W.  S.  (56).    "Referred  Pain  in  Surgical  Conditions."    J.  A. 

M.  A.,  Nov.  2,  1907,  1549. 
EsTES  (555).     "Referred  Pain."     Penn.  Med.  Jour.,  June,  1908,  ii, 

No.  9. 
EuLENBERG  (145).     "Ueber  die  Bezieliungen  der  functionellen  Ner- 

venkrankheiten   zu   den   weibliclien    Geschlechtsorganen   in   ato- 

logischer,  diagnostischer  und  therapeutischer  Hinsicht."    Central- 

blatt  f.  Gyn.,  1903,  xxvii,  1274. 

(509).     "Functionelle  Krankheiten,"  31. 

.     "Spinale  Halbseitenlasion   (Brown-Sequard'sche  Lahmung)." 

Deutsche  med.  Woch.,  1892,  xviii,  845. 
Everett,  J.  T.   (566).     "Studies  in  Relation  to  the  Production  of 

Pain  by  the  Weather."     Chicago  Med.  Jour,  and  Exam.,  1879, 

xxxviii,  253-260. 
EwEN,  E.  W.    "Skin  Sensitization."    111.  Med.  Jour.,  February,  1912, 

xxi,  No.  2. 
Faber.     "Referred  Pain  in  Visceral  Diseases;  Fifteen  per  cent,  of 

Two  Hundred  Cases  of  Intestinal  Diseases."     Deutsches  Archiv 

f.  klin.  Med.,  Ixv,  1900,  332. 
Faber,  E.  E.  (55,  187,  592,  616).    "Pain  in  Adipose  Tissue."    Hos- 

pitalstedende,  Copenhagen,  June  26,  1907,  No.  26;  July  3,  1907, 

No.  27;  J.  A.  M.  A.,  1907,  Ixix,  1408. 
Fanchild,  D.  S.     "The  Diagnostic  Value  of  Pain  in  Intraabdominal 

and  Pelvic  Diseases."     Iowa  Med.  Jour.,  Des  Moines,  Aug.  15, 

1901. 
Fechner.    "Vorschule  der  Aesthetik,"  i,  8. 
Feilchenfeld,  H.     "Ueber  den  Blendunffsschmerz."     Zeitschrift  f. 

Psychol,    u.    Physiol.,    Leipzig,    1908,    xlii,    2te    Abtheil.,    313- 

348. 

(1079).     "Ueber  das  Wesen   des   Schmerzes."     Zeitschrift  f. 

SinnesphysioL,  Leipzig,  1907,  xliii,  172-191. 

Fenwick,  E.  H.    "Kidney  Pain."    British  Med.  Jour.,  London,  Jan. 

7,  1911.     Ab.  in  J.  A.  M.  A.,  Ivi,  5,  382. 
Fenwick,  p.  C.     "Genitourinary  Pain."     Australasian  Med.   Gaz., 

Sidney,  1899,  xviii,  182-186. 

(569).     "Cardinal  Symptoms  of  Urinary  Disease."    J.  and  A. 

Churchill,  1893,  240. 


822  BIBLIOGRAPHY 

Fenwick,  p.  C.   (793).     "The  Clinical  Significance  of  Pain  in  the 

Epigastrium."    Med.  News,  Mar.  19,  1904,  540.     Quoted  by  Dr. 

Frank  Murdock. 
Fere,  C.  (837).     "Douleur  et  fatigue."     Compt.  rend.  soc.  de  bioL, 

Paris,  1905,  lix,  12-15. 
Fernseed,  J.    "The  Philosophy  of  Pain."    Jour.  Sci.,  London,  1881, 

iii,  336-342. 
Ferreira  de  Castro.    "Tratamento  dos  grandes  symptomas;  a  dov." 

Med.  Mod.,  Porto,  1895,  ii,  19G;  1896,  iii,  207-217. 
Ferrier  (422).     "Cerebral  Localization."    London. 

• .     "Physiologic  Discord." 

Ferrier  and  Ballance  (394).     "Case  of  Eecovery  After  Operation 

for  Cauda  Equina  Lesion."     Brain,  xxvii,  431. 
Ferrier  and  Horsley,  Sir  Vict.    "Case  of  Recovery  After  Operation 

of  a  Tumor  of  Cauda  Equina."    Brain,  xxvii,  432-433. 
Fisher,  E.  D.  (611).     "Pain  in  Tabes  Dorsalis."    J.  A.  M.  A.,  liii, 

No.  5,  405. 
FiTE,  W.    "The  Place  of  Pleasure  and  Pain  in  Functional  Psychol- 
ogy."    Psychol.  Eev.,  N.  Y.  and  London,  1903,  x,  633-644. 
Fleisch^  J.   (614).     "Treatment  of  Sciatica."     Med.  Klinik,  Berlin, 

Jan.  3,  vi,  1-40.    Ab.  in  J.  A.  M.  A.,  Jan.  23,  1909,  336. 
Fleming,  Egbert.     "Neurasthenia  and   Gastralgia."     Practitioner, 

January,  1911^  29. 
Fleming,  E.  A.    "A  Clinical  Lecture  on  Sciatica."    Med.  Press  and 

Circular,  London,  1908,  N.  S.,  Ixxxv,  682-684. 
Flesch,  J.     "Treatment  of  Sciatica  with  Saline  Injections."     Med. 

Klin.,  Berlin,  Jan.  3,  v.  No.  1,  1-40. 
Fletcher,  W.  M.   (448).     "Tetanus  Dolorosus  and  the  Eelation  of 

the   Tetanus   Toxin   to    Sensory   Nerves    and    Spinal    Ganglia." 

Brain,  xxvi,  383. 
Flint,  E.  M.    (763).     "Pain."     Med.  Dial,  Minneapolis,  1898-99, 

i,  74. 
Forbes,  A.  M.    "Notes  on  Anterior  Metatarsalgia."    Montreal  Med. 

Jour.,  1909,  xxxviii,  233-237. 
FoRBES-Eoos,  F.  W.   (313).     "Discussion  on  the  So-called  Ovarian 

Pain,  Its  Causes  and  Treatment."     British  Med.  Jour.,  1904, 

1063. 
Forsyth,  D.  (58,  126,  808).    "A  Lecture  on  Eef erred  Pain  and  Its 

Diagnostic  Value."    British  Med.  Jour.,  London;,  June  22,  1907, 

i,  1467-1471. 
Fortingill,  W.   E.    (310).     "Discussion  on  the   So-called  Ovarian 

Pain,  Its  Cause  and  Treatment."    British  Med.  Jour.,  1904,  1062. 


BIBLIOGRAPHY  823 

FoTHERGiLL^  J.  M.  "The  Logic  of  Pain."  Contemp.  Eev.,  London, 
1884,  xlv,  680-686. 

FouQUET  (370).  "Hospital  de  Cayenne.  Phlegmon  sous-aponcoro- 
tique  et  intramusculaire  de  la  parsi  abdominale."  Gaz.  des  Hop., 
Paris,  1884,  Ivii,  315. 

PouRNiER,  A.  (21,  274).  "Blenorrhagie."  Nouveau  diet,  de  med., 
V,  237. 

FovEAU  DE  CouRMELLES.  "Les  etapes  de  la  douleur."  Med., 
Bruxelles,  1904,  xiv,  25. 

Fowler  and  Godlee  (106).     "Diseases  of  the  Lung,"  670. 

Fraentzel  (101).  Article  on  diseases  of  chest.  Ziemssen's  Encyclo- 
pedia.    Am.  trans.,  iv,  632. 

(110)-     Article  on  pleurisy.     Ziemssen's  Encyclopedia.     Am. 

trans.,  xvii,  63. 

Franck^  F.     "Eecherches  experimentales  sur  les  effets  cardiacques, 

vasculaires,  et  respiratoires  des  excitations  douloureuses."   Compt. 

rend.  acad.  de  sci.,  Paris,  1876,  Ixxxiii,  1109-1111. 
Frankl-Hochavart.     "Ueber  Prognose  und  Diagnose  der  Ischias." 

Mitt.  d.  Gesellsch.  f.  phys.  Med.,  Wien,  1909,  ii,  2-6. 
Franz^  S.  J.    "Sensations  Following  Nerve  Divisions."    Jour.  Compt. 

Nerv.  and  Psychol.,  Philadelphia,   1909,  xix,  107-123. 
Fredericq,  L.  (594).     "Y-a-til  des  nerfs  speciaux  pour  la  douleur?*' 

Eev.  sci.,  Paris,  1896,  vi,  713-717. 
Freund,  W.  a.   (136).     "Beitrage  zur  Anatomic  der  ausgetragenen 

extra-uterine  Gravitat."    Beitrage  zur  Geburtshilfe  u.  Gynacolo- 

gie,  1903. 
Frey,   Max  von    (207).      "Beitrage   zur   Physiologic   des    Schmerz- 

sinnes."     Berichte  iiber  die  A^erhandlungen  d.  konigl.  sachs.  Ge- 

sellschaft  d.  Wissenschaften,  1894,  ii,  185. 

(207,   219,   220,   221).      "Beitrage   zur   Sinnesphysiologie   der 

Haut."  Berichte  iiber  die  Verhandlung  d.  konigl.  siichs.  Gesell- 
schaft  d.  Wissenschaften,  1894,  iii,  185-196;  1894,  iii,  283-296; 
1895,  ii,  166;  1897,  iv,  462. 

(210).     "The  Distribution  of  Afferent  Nerves  in  the  Skin." 

J.  A.  M.  A.,  Sept.  1,  1896,  xlvii,  645. 

(216,  223).     "Ueber  den  Ortsinn  der  Haut."     Sitzungb.   d. 

phys.  med.  Gesellschaft,  Wiirzburg,  Nov.  9,  1899.  Jahrgang, 
1902. 

.     "Untersuchungen  iiber  Sinnesfunction  der  Haut."     Leipzig, 

1896. 

(222,  409).     "Untersuchungen  iiber  die  Sinnesfunctionen  der 

menschlichen  Haut.    Erste  Abhandlung."    Abhandlung  d.  math. 


824  BIBLIOGRAPHY 

phys.    Klasse    d.    konigl.    siichs.    Gesellschaft    d.    Wissenschaft, 
1896,  175. 
(457).     "Vorlesungen  iiber  Physiologie."     Berlin,   1903,  308. 


Fritsch  (348).  "Ueber  Adnexa-Operationen."  Deutsche  med. 
Woeh.,  1899,  No.  40,  v,  244. 

Fkohlicii,  a.,  and  Meyer,  H.  H.  "Sensible  Innervation  von  Darm 
und  Harnbiase."  Wiener  klin.  Woeh.,  Jan.  4,  1912,  xxv.  No. 
1,  29. 

Fry^  F.  E.  "Imperative  Pains."  Jour.  Nerv.  and  Ment.  Dis.,  Lan- 
caster, Pa.,  November,  1911,  xxxviii,  No.  11,  641-677.  Ab.  in 
J.  A.  M.  A.,  Dec.  9,  1911,  Ivii,  24,  1945. 

FuNKHOUSER,  E.  M.  "Diagnostic  Significance  of  Abdominal  Pain." 
Jour.  Missouri  State  Med.  Assoc,  Aug.,  1911.  Ab.  in  J.  A.  M. 
A.,  Sept.  16,  1911,  vii,  12,  1007. 

Gad  and  Heymann.  "Kurzes  Lehrbuch  der  Physiologic  des 
Menschen."     Berlin,  1892. 

Gaddes,  T.  (565).  "Some  Observations  on  the  Physiology  and  Seat 
of  Pain."  Britisli  Jour.  Dent.  Society,  London,  1891,  xxxiv, 
972-976. 

Gallabin  (319).     "Diseases  of  Women."    6th  ed.,  475. 

Gamelle^  J.  "De  la  douleur;  des  moyens  dits  anesthesiques,  quel 
sont  les  avantages  et  les  dangers  qui  peuvent  resulter  de  leur 
emploi;  comment  pourrait-on  prevenir  ces  dangers."  Jour,  de 
med.,  ehir.  et  pharmac,  Bruxelles,  1855,  xx,  41,  133,  318,  534; 
xxi,  140,  338,  431,  518. 

Gant  (91).  "Pain  in  Constipation."  Constipation  and  Intestinal 
Obstruction  (W.  B.  Saunders  Co.),  141-142. 

Garcin^  E.  D.  "Pain,  Its  Importance  in  Health  and  Disease."  Virg. 
Semi-month.,  Eichmond,  1904-05,  ix,  268-270. 

Garrigues,  L.  F.  (163,  803).  "The  Causes  and  Treatment  of  Back- 
ache in  Women."    J.  A.  M.  A.,  Jan.  2,  1909,  11-13. 

Gaskell  (195).  "On  the  Structure,  Distribution  and  Function  of 
the  Nerves  Which  Innervate  the  Visceral  and  Vascular  Systems." 
Jour.  Physiology,  vii,  1. 

Gasser,  Herman  (99).  "The  Physiology  of  Pain."  Med.  Times, 
N.  Y.,  1903,  xxxi,  168,  198. 

.  "Pleasure  and  Pain  and  Consciousness."  Tr.  Med.  Soc,  Wis- 
consin, Madison,  1897,  xxxi,  562-577. 

Gaub^  0.  C.  "The  Surgical  Aspect  of  Pain  Occurring  in  the  Epi- 
gastrium."    Penn  Med.  Jour.,  September,  1902,  v,  541-633. 

Gauble,  D.  "On  the  Influence  of  Pain  in  the  Production  of  Death." 
Southern  Med.  and  Surg.  Jour.,  Augusta,  1838,  ii,  707-713. 


BIBLIOGRAPHY  825 

Gauthier^  E.  "Essai  snr  le  stoicisrnc  avec  leqiiel  certains  malades 
supportent  la  douleiir  d'operations  chirurgicalcs."  Jour.  gen.  de 
nied.,  ehir.  et  pharm.,  Paris,  1813,  xlvii,  233-247. 

Gat.     "Diphtherial  Paralysis-Allocheiria."     Brain,  1893,  iii,  431. 

Geyer,  H.  E.  (353).  "Diagnostic  Value  of  Pain."  Ohio  Med.  Jour., 
Columbus,  1907,  ii,  402-40G. 

Ghladen.  "Pain,  Its  Physical  Diagnosis.''  Med.  Exam,  and  Prac- 
titioner, K  Y.,  1908,  xviii,  233-235. 

GiBNEY  (260).  "The  Diagnosis  of  Hip  Disease."  Am.  Jour.  Med. 
Sci.,  1877,  i,  399;  1878. 

(261).     Chicago  Med.  Jour,  and  Exam.,  June  2,  1880. 

GiBSOX^  G.  A.    (250).     "Some  Hitherto  Undescribed  Symptoms  in 

Angina  Pectoris."     Brain,  xxviii,  52-64. 

(251).     "Morrison  Lectures." 

GiLBRiDE,  John  J.  (63).  "The  Clinical  Significance  of  Pain  in  the 
Epigastrium."  J.  A.  M.  A.,  February,  1908,  361;  Am.  Med., 
Philadelphia,  1908,  iii,  81-85. 

(582,  800,  845).    Penn.  Med.  Jour.,  xi,  361,  363. 

GiLLES,  H.  C.  "The  Xatural  History  of  Pain."  Caledonian  Med. 
Jour.,  Glasgow,  1894-96,  ii,  335-343. 

GiLMAN.  "Syllabus  of  Lectures  on  the  Psychology  of  Pain  and 
Pleasure."     Am.  Jour,  of  Psych.,  vi,  i,  3-60. 

Giovanni,  A.  de  (164).  "II  dolore  celiaco."  Gazzetta  degli  Ospe- 
dale  e  delle  Cliniche,  Milano,  Apr.  3,  1910,  Xo.  40,  417. 

GoLDiNG-BiRD  (671).  "Nodal  Pains."  Guy's  Hosp.  Gaz.,  London, 
1897,  xi,  26-29. 

GoLDSciiEiDER,  A.  (47,  146,  253).  "Ueber  die  Behandlung  des 
Schmerzes."  Berliner  klin.  Wochensch.,  1896,  xxxiii,  49,  78, 
102 ;  Yeroffentl.  d.  Hufeland  Gesellschaft,  Vortrag,  Berlin, 
1895-96,  80-105;  Arztliche  Eunuschau,  Mtinchen,  1896,  vi, 
67-81. 

.  "0  boli  s  fiziologicheskoi  i  kliuicheskoi  tochki  zriemya."  Mos- 
cow, 1895. 

(22,  277).   "Concerning  Bronchialgia."   Therapeutische  Monats- 

hefte,  December,  1909. 

(-161).     "Diagnostik  der  Krankheiten  des  Nervensystems."  2te 

Auflage,  V,  21  f. 

(215).    "Gesammelte  Abhandlung."    Leipzig,  1898,  i. 

.     "Zur  Lehre  von  der   Hautsensibilitiit."     Zeitschrift  f,   klin. 

Med.,  Berlin,  Ixxiv,  No.  3. 
.     "Ueber  den  Schmerz  in  physiologischer  und  klinischer  Hin- 

sicht."     Berlin,  A.  Herschwald,  1894. 


826  BIBLIOGRAPHY 

GoLDSCHEiDER,  A.  "Temperature  Spots."  Gesammelte  Abhand- 
lungen,  Leipzig,  1898,  i. 

.     "Neue  Thatsachen  liber  Hautsinnesnerven."     Archiv  f.  Ana- 

tomie  u.  Physiol.,  1885,  Physiologische  Abt.  Supplementband. 

■ .     "Ueber     verlangsamte     Leitung     der     Schmerzempfindung." 

Deutsche  med.  Woch.,  Leipzig  and  Berlin,  1890,  xvi,  688 ;  Arbeit 
a.  d.  1.  med.  Klinik  zu  Berlin,  1891,  ii,  210-214;  Gesammelte 
Abhandlungen,  Leipzig,  1898,  i,  391-396. 

GoLDWAiTiiE,  Joel  E.  "Pain  Due  to  Loose  Sacroiliac  Joints."  Bos- 
ton Med.  and  Surg.  Jour.,  1905,  593-594. 

(800).     "Sacroiliac    Dislocation."      Annals    Surg.,    li.    No.    3, 

420. 

GooDHART^  S.  P.  "Cervical  Eib  and  Its  Eelation  to  the  Neuropathias, 
with  Eeport  of  a  Case."  Jour,  of  Ment.  and  Nerv.  Dis.,  Lan- 
caster, Pa.,  1908,  XXXV,  586. 

Gordon,  A.  "A  Case  of  Unilateral  Hemorrhage  into  the  Medulla, 
Followed  by  Syringomyelic  Sensory  Disturbances."  Jour.  Ment. 
and  Nerv.  Dis.,  N.  Y.,  1908,  xxxv,  257. 

(600,  608).     "Malignant  Disease  of  the   Sacrum   Simulating 

Sciatica."    J.  A.  M.  A.,  Mar.  26,  1910,  1022. 

.     "A  jSTew  Precision  Esthesiometer."     J.  A.  M.  A.,  1909,  Hi, 

1257. 
.     "Pathogenesis  of  Stump  Hallucination  Apropos  of  a  Case  of 

Twenty-seven  Years'  Standing."     N.  Y.  Med.  Jour.,  1908,  Ixxx. 

(562).     "Stump  Hallucinations."     N.  Y.  Med.  Jour.,  Jan.  4, 

1908,  17. 

GoTZ.  "Die  lokale  Herabsetzung  des  Schmerzsinnes  durch  den  elek- 
trischen    Strom."      Monatschrift   f.    prakt.    Dermat.,    Hamburg, 

1907,  xlv,  501. 

Gould.    "Kopfschmerz  und  Augeniiberanstrengungen."    J.  A.  M.  A., 

1908,  No.  1. 

GovLEY,  J.  W.  (271).     "Genitourinary  Diseases."     1873,  16. 
GowERS.     "Manual  of  Diseases  of  the  Nervous   System."     2d  ed., 

1982-93. 
Graham,  F.  W.     "Pain  from  a  Diagnostic  Point  of  View."     Phys. 

and  Surg.,  Ann  Arbor,  Mich.,  1889,  xi,  385-392. 
GR.VNGER,  Stewart.    Jour.  Advanc.  Th.,  N.  Y.,  1909,  xxvii,  470-480. 
and  Holmes.    "Symptomatology  of  Cerebellar  Tumors."  Brain, 

1904,  54. 
Granville,   J.    Mortimer    (489,    917).      "Treatment   of    Pain   by 

Mechanical  Vibrations,"  Lancet,  London,  Feb.  19,  1881,  i,  286- 

288. 


BIBLIOGRAPHY  827 

Gray  (702,  706).     "Anatomy,"  1134,  1135. 

Greiff.     "Zur  Lokalisation  der  Hemichorea."     Archiv  f.  Psychiatrie 

u.  Nervenkrankheiten,  xiv,  598. 
Griesinger,  W.     "Ueber  den  Schmerz  und  iiber  die  Hyperaemie." 

Archiv   f.    physiologische    Heilkiinde,    Stuttgart,    181:3,    i,    538- 

575. 
Griffith^  J.  Crosier.    "Eeports  of  Interesting  Cases,  Containing  an 

Article  on  Peritonilx'  Pneumonia.""     Arch.  Pediat.,  June,  1899, 

418. 
.     "Pneumonia  and  Pleurisy  in  Early  Life  Simulating  Appendi- 
citis."'   J.  A.  M.  A.,  Aug.  29,  1903,  531. 
Grinker^  J.    "Subacute  Combined  Cord  Degenerations,  with  Eeport 

of  Cases."     J.  A.  M.  A.,  1908,  1,  1109-1115. 
Groesbeck,  H.  p.     "Pelvic  Surgery  in  Eelation  to  Periodic  Head- 
aches and  Neuralgia."    N.  Y.  State  Jour.  Med.,  Feb.,  1912,  xii, 

No.  2. 
Gross,  S.  D.    (264,  482).     "Proximate  Causes  of   Pain."     Trans. 

A.  M.  A.,  1877,  572-580. 

.     "Surgery."     Philadelphia,  1872,  ii,  1054. 

Grossman,  J.     "Sur  I'epigastralgie  d'origine  arterielle."     Arch,  de 

malad.  de  I'apparat  dig,  etc.,  Paris,  1908,  ii,  206-218. 
Grube,  E.  H.    "Pain,  Abdominal."    Ab.  in  J.  A.  M.  A.,  Ivi,  No.  21, 

1601. 
GuBB   (1200,  Gendrie,  742).     "Subcutaneous  Injection  of  Air  as  a 

Means  of  Eelieving  Certain  Painful  Manifestations."     British 

Med.  Jour.,  London,  1907,  ii,  1297-1299. 
Guernot,  a.    "Eecherches  sur  les  conditions  de  la  douleur."  (Lyons.) 

Chalons-sur-Saone,  1900. 
GuiNON  (455,  759).     "Painful  Abdominal  Paroxysms  in  the  Course 

of  Purpura."     Eevue  des  mal.   des  enfants,    December,    1907. 

Ab.  in  J.  A.  M.  A.,  1908,  613. 

(493).      Soc.    de    Pediatric    de    Paris,    Seance    du    Mars    12, 

1901. 

and  DuTiL.     "Deux  cas  de  maladie  de  Morvan."     Nouvelle 

Monographic  de  la  Salpetriere,  1890,  iii,  1. 

GuNENO  and  Calanas.     "El  dolor."     Cr.  med.,  Valencia,  1886-87. 

X,  39,  70. 
GuYON   (127).     "Semiologie  de  la  douleur."     Annales  de  mal.  des 

organes  genitourinairis,  Paris,  1895,  xiii,  961-978. 
Habershon  (802).     Lancet,  Nov.  19,  1859,  551. 
Haehnel.    "Ueber  Kopfschraerzen."    Miinchener  med.  Woch.,  1906, 

No.  23,  1121. 


828  BIBLIOGRAPHY 

Hald,  p.  T.     "A  Simple  Method  of  Relief  in  Certain  Forms  of 

Odynphagia."     Medical  Record,  Feb.  25,  1911,  333. 
Hall^  J.  N.  (528).    Article  on  pain.    "Physiology." 
.     "The  Causes  of  Epigastric  Pain."    Denver  Med.  Times,  1903, 

xviii,  254-259. 
Haller    (341).     Article   about   abdominal   pain   in   the    Elementa 

Physiologic,  1757-17GG. 
Halperin.    Archiv.  Int.  Med.,  xi,  No.  3,  326. 
Hammond.     "Kopfschmerz  und  Ohrenerkrankung."     J.  A.  M.   A., 

1908,  No.  1. 
Hammond,  J.  Jay   (51).     "Abdominal  Pain  in  Atypical  Appendi- 
citis."   Ab.  in  J.  A.  M.  A.,  Oct.  26,  1907,  xlLx,  1465. 
Hampeln,  p.   (105).     Loc.  cit.,  455. 
.     "Ueber  schwere   abdominal  Erscheinungen  in  Beginn  einer 

Pneumonic  oder  Pleuritis."    Ztsch.  f.  klin.  Med.,  xlv,  1902,  448. 
.     "Ueber  Spinalschmerzen."     Berliner  klin.   Woch.,  1908,  xlv, 

863-866. 
Hansen,   H.     "Naergaaende  barometriske   depressoners  forhold  til 

dolores  acuta  sine  nota  causa."    Ugeskr.  f.  Laeger,  Kjobenhavn, 

1903,  V.  r.  X,  145-159. 
Hanusa,  K.    "Auftreten  von  hyperalgetischen  Zonen  nach  Schadel- 

verletzungen."    Mitteil.  a.  d.  Grenzegeb.  d.  Med.  u.  Chir.,  xxiv. 

No.  2,  255. 
Hardestt,  J.    (423).     "Further  Observations  on  the  Number  and 

Arrangement  of  Spinal  Nerve  Fibers."    Jour.  Comp.  Neurology, 

1900,  i,  X,  323-354. 
Harris.     "Kopfschmerzen."     Lancet,  1907,  No.  4353. 
Harris,  Philander  A.  (846).    "Method  of  Obtaining  More  Reliable 

Knowledge  of  the  Exact  Areas  of  Pain  Complained  of  by  Patients 

Afflicted  with  Visceral  Disease."     Surgery,  Gynecology  and  Ob- 
stetrics, 1909,  ix,  No.  6,  638-647. 
Harris,  Wilfred  (132,  631,  774,  786).    "Causation  and  Treatment 

of  Some  Headaches."     Lancet,  Feb.  2,  1907,  276-278. 
.     "Diagnosis  and  Treatment  of  Sciatica."    Clin.  Jour.,  London, 

1908-09,  xxxiii,  220-224. 
.   (203).     "Report   of  a  Case   of   Transverse   Sacral   Myelitis." 

Brain,  xxviii,  364. 
Harrison,  J.  C.    "On  the  Physiological  Pathology  and  Therapeutics 

of  Pain."     Western  Lancet,  Cincinnati,  1849,  ix,  349-354. 
Harsha,  W.  M.    "Pain  in  Abdominal  Disease."    South.  Med.  Jour., 

Nashville,  December,  1910. 
Hart,  David   (276).     "Sympathetic  Pain."     Practitioner,  London, 

1878,  xxi,  342-346. 


BIBLIOGRAPHY  829 

Hartenberg,  P,  "Les  cephales  miisculaires."  Presse  Med.,  Paris, 
Feb.  14,  1912.  "Headache  from  Chronic  Cervical  Myositis." 
Ab.  in  J.  A.  M.  A.,  Mar.  23,  1912,  Iviii,  12,  899. 

Hartmanx  (782).    Deutsche  med.  Woch. 

.     "tTeber    nasalen    Kopfschmerz    und    nasale     Neurasthenic." 

Deutsche  med.  Woch.,  1907,  No.  18. 

Hasselman,  J.     "De  dolore  in  geuere."     Lugd.  Bat.,  1728. 

Hauff.  "Einige  Bemerkungen  iiber  die  normale  und  abnorme 
Thatigkeit  der  sensiblen  Nervenj  iiber  Empfindung  und 
Schmerz."  Archiv  f.  die  gesammte  Medizin,  Jena,  1845,  vii, 
113-147. 

Havilaxd,  Hall  (811).  "Hypostatic  Albuminuria  of  Splenic  Ori- 
gin."    Lancet,  1902,  i,  593. 

Haworth  (557).  "Pain  in  Left  Clavicle."  Penn.  Med.  Jour.,  June, 
1908. 

Haydex,  a.  M.  "Pain  and  Its  Significance."  Kentucky  Med.  Jour., 
Feb.  15,  1912,  x,  No.  4. 

Hayem.  "Mise  en  ceuvre  de  la  medication  de  la  douleur."  Annales 
de  med.  sci.  et  prat.,  Paris,  1891,  i,  105-109. 

Head.  "The  consequences  of  Injury  to  the  Peripheral  Xerves  in 
Man."     Brain,  1905,  xxviii,  116. 

(218).     Article  on  pain.     Quain's  Diet.  Med.,  3d  ed. 

(14,  26,  104,  333,  334,  711,  738).  "A  Disturbance  of  Sensa- 
tion, with  Special  Reference  to  the  Pain  of  Visceral  Disease." 
Brain,  1893,  xvi,  1-133,  79,  82;  Brain,  1894,  xvii,  339-480; 
Brain,  1896,  xix,  153-276;  Brain,  1900. 

(418).     Marshall   Hall   address.     Eoyal   Med.    Chir.    Society, 

May  23,  1905. 

and  Campbell,  A.  W.  (336-400).  "Pathology  of  Herpes  Zos- 
ter and  Its  Bearing  on  Sensory  Localization."  Brain,  1900, 
part  III,  352-523. 

H.,  and   Holmes,   G.     "Sensory  Disturbances  from   Cerebral 

Lesions."     Lancet,  Jan.  6,  13,  20,  1912,  No.  3.     Ab.  in  J.  A. 
M.  A.,  Feb.  10,  1912,  Iviii. 

EiVERS,  and  Sherren   (85).     "The  Afferent  Nervous  System 

from  a  New  Standpoint."     Brain,  1905,  part  II,  xxviii,  98-115. 

.     "The  Grouping  of  Afferent  Impulses  Within  the 

Spinal  Cord."     Brain,  1906,  xxix,  538. 

and  SiiEBREX   (194,  244,  395).     "The  Consequences  of  Injury 

to  the  Peripheral  Nerves  in  Man."    Brain,  1905,  xxviii,  99,  116- 
338,   339-388,   the  latter   from   ref.    244. 

— -  and  Thompson,  Theo.  (206,  209).    "On  the  Grouping  of  Af- 


830  BIBLIOGRAPHY 

ferent  Impulses  Within  the  Spinal  Cord."     Brain,  1906,  xxii, 

537-743. 
Heard,  J.  D.     "Some  General  Considerations  in  Regard  to  Right 

Cardiac  Pain."    Interstate  Med.  Jour.,  Sept.,  1911. 
IIeelin,  John  B.  (311).    "Discussion  on  the  So-called  Ovatian  Pain, 

Its  Causes  and  Treatment."     British  Med.  Jour.,  1904,  1062. 
Helbich,  K.     "Kekolik  myslenek  o  nasich  bedach"   ("Our  Pains"). 

Vestnik,  V.  Praze,  1901,  xiii,  181-183. 
Henderson  (570).  "Pain,  Acapnea  and  Shock."  Am.  Jour.  Physiol., 

February,  1910.     Ab.  in  J.  A.  M.  A.,  Feb.  26,  1910,  744. 
Henle  (378).     "Anatomic  des  Menschen."     Quoted  by  Gaskell   (q. 

v.),  27. 
Henri,  Victor  (214).     "Ueber  die  Eaumwahrnehmungen  des  Tast- 

sinnes."    Berlin,  1898. 
Henschen.     "Klinische  und  anatomische  Beitrage  zur   Pathologic 

des  Gehirns."    Upsala,  1890. 
Herman  (904).     "Gynecologic  Pain."    Year  Book  Series,  1909,  iv, 

206. 
Herman,  G.  E.  (144,  236,  316,  324).    "Discussion  on  the  So-called 

Ovarian  Pain,  Its  Causes  and  Treatment."    British  Med.  Jour., 

1904,  ii,  1055. 
Hermans  (318).    "On  the  Frequency  of  the  Local  Symptoms  Asso- 
ciated   with    Backward    Displacement    of   the    Uterus."      Obst. 

Trans.,  xxxv,  1893. 
Herrick  (722).     Osier's  "System  of  Medicine,"  vi,  178. 
.     "Abdominal  Pain  in  Pleurisy  and  Pneumonia."    J.  A.  M.  A., 

Aug.  29,  1903,  535. 
Herrick,  J.  B.     "Pain  in  Disease  of  the  Heart."    Jour.  Iowa  State 

Med.  Assoc,  Oct.  15,  1911. 
Herrick,  J.  T.  (15,  150).    "Abdominal  Pain  in  Pleurisy  and  Pneu- 
monia."    Illus.    Med.   Jour.,    Springfield,   1903-04,   v,   603-611; 

J.  A.  M.  A.,  1903,  xli,  535-540. 
Herringham,  W.  p.    "A  Clinical  Lecture  on  Hemianesthesia  of  the 

Dissociated    Form."      Clinical    Journal,    London,    1909,    xxxiv, 

65-67. 

(597).     "Xeuralgia  of  Brachial  Plexus  Resulting  from  Arthri- 
tis of  the  Shoulder  Joint."    Proc.  Roy.  Soc.  Med.,  Dec,  1907,  31. 

(354).     "Pain  in  Lower  Part  of  Abdomen."    Clin.  Jour.,  Lon- 
don, 1906-07,  xxix,  302. 

Hertz,  Arthur  F.    "Sensibility  of  the  Abdominal  Tract."    Univer- 
sity of  Oxford  Press,  London,  1911. 
Hetzrot   (337).     "Cellulitis  and  Myositis  of  the  Abdominal   V.'n.; 


BIBLIOGRAPHY  831 

Simulating  Intraabdominal  Conditions."     J.  A.  M.  A.,  Mar.  2, 

1907. 
HiCHT,  D.  0.    "Treatment  of  Sciatica  by  Deep  Perineural  Injections 

of  Salt  Solution."    J.  A.  M.  A.,  1909,  lii,  444-449. 
Hill,  E.  C.  (98).    "Pain  and  Its  Indications."    J.  A.  M.  A.,  March, 

April,  May,  June,  1902,  xxv,  60,  116,  187,  240,  307,  359,  413, 

547,   605,   665;   1903,  xxvi,   21,   71,   125,   172,  230,   280,   334; 

Med.  Standard,  Chicago,  June,  1903. 
.     "On  the  Trail  of  a  Pain."     Trans.  Col.  Med.  Soc,  Denver, 

1902,  163-165. 
HiLLER  (373).    "Ueber  Tuberkulose  der  Bauchdecken  muskulator." 

"Beitrage  zur  klinischen  Chirurgie."  1899,  xxv,  826. 
Hilton  (38,  740,  757).  "Eest  and  Pain."  1877,  169,  274. 
HiNSHELwooD.     "Ocular   Headache."     Glasgow   Med.   Jour.,   Nov., 

1900. 
HiRSCH.     "Habitueller  Kopfschmerz."     St.  Petersburger  med.  Woch., 

1909,  No.  37. 
Hodge   (1028).     "Pain  in  the  Upper  Abdominal  Zone,  Its  Causes 

and  Diagnosis."    Dominion  Med.  Monthly,  Toronto,  1904,  xxiii, 

1202-1209. 
HoESSLiN,  R.  VON.     "Ueber  die  Bestimmung  der  Schmerzempfind- 

lichkeit   der   Haut   mit    dem   Algesimeter."      Miinchener   med. 

Woch.,  1903,  1,  250-253. 
HOFMEISTER,  I.    (869).     "Ueber  die  Behandlung  brandiger  Briiche 

mit  primarer  Darmresektion."    Bruns'  Beitr.  z.  klin.  Chir.,  1900, 

xxviii,  3. 
HoLDEN  (902).     Boston  Med.  and  Surg.  Jour.,  June  6,  1907. 
Holmes,  G.    "On  the  Relations  Between  Loss  of  Function  and  Struc- 
tural Change  in  Focal  Lesions  of  the  Central  Nervous  System, 

with  Special  Reference  to  Secondary  Degeneration."   Brain,  1906, 

iv,  514. 
Holmes,  G.,  and  Kennedy,  R.  F.     "Syringomyelia  Without  Symp- 
toms Associated  with  Intracranial  and  Spinal  Tumors."     Proc. 

Roy.  Med.  Soc,  London,  1908,  i,  ii,  sec.  4. 
Holsti  (391).    "Ueber  die  Veranderungen  der  feineren  Arterien  bei 

der    kleineren    Nierenatrophie    und    desen    Bedeutung    fiir    di& 

Pathologic  dieser  Krankheiten."    Deutsches  Archiv  f.  klin.  Med., 

1885,  xxxviii,  122. 
Hood   (323,  755).     "Some  of  the  Clinical  Aspects  of  Pneumonia." 

Lancet,  Dec.  30,  1905,  1881-1885. 
Hoover    (554).     "Traumatic  Encephalitis."     Address.     College  of 

Physicians  of  Pittsburgh,  1909. 


832  BIBLIOGRAPHY 

HoppE,  H.  H.  "A  Critical  Study  of  the  Sensory  Functions  of  the 
Motor  Zone  (Pre-Rolandic  Area),  More  Especially  Stereognosis." 
Jour.  Ment.  and  Nerv.  Dis.,  Lancaster,  Pa.,  1909,  xxxvi,  513- 
527. 

HowEi^L,  C.  M.  (23,  287,  751,  1164).  "Acute  Abdominal  Pain." 
Practitioner,  1906,  xxvii,  440-147;  1909,  vii,  441. 

(525).    "Pain;  General  Consideration.'-     Physiology,  1909,  281. 

(539).    "Terminal    Nerve    Endings,    Tendons."      Physiology, 

1909,  281. 

Howie,  P.   (661).     "A  Case  of  Epigastralgia."     Scottish  Med.  and 

Surg.  Jour.,  Edinburgh,  1905,  xvi,  522-526. 
Hubbard,  J.  C.   (590,  749,  836).     "Morris'  Point  of  Tenderness  as 

an  Aid  in  Diagnosis."    Boston  Med.  and  Surg.  Jour.,  clix.  No. 

27,  895-898. 
Hummel,  E.  M.    "Neuralgic  Pain  in  Nerves  Pressed  on  by  Inflam- 
matory Exudate  and  Scar  Tissue."    New  Orleans  Med.  and  Surg. 

Jour.,  Jan.,  1910. 
Humphries,  F.  H.  (64).     "What  Is  Pain?     An  Attempt  to  Define 

Its  Origin  and  Nature."    Am.  Phys.,  N.  Y.,  1908,  xxxiv,  66-75 ; 

Jour.  Advanc.  Therap.,  N.  Y.,  1908,  xxvi,  63-78. 
Hunt,  J.  R.    "A  Progressive  Lesion  of  the  Eoot  of  the  Fifth  Nerve 

Producing  Motor  Sensory  and  Trophic  SATiiptoms."    Jour.  Nerv. 

and  Ment.  Dis.,  Lancaster,  Pa.,  and  N.  Y.,  1905,  xxxii,  792. 
Huss,  M.  (102).    "Ueber  den  anderseitigen  pleuritischen  Schmerz." 

Deutsches  Archiv  f.  klin.  Med.,  ix,  242. 
HussEY,  F.  V.     "Trifacial  Neuralgia."    J.  A.  M.  A.,  1909,  liii,  706- 

712. 
Hutchinson,  H.  S.     "Arteriosclerosis  of  the  Central  Nervous  Sys- 
tem, with  a  Report  of  Three  Cases."     Univ.  Penn.  Med.  Bull., 

Philadelphia,  1907-08,  xx,  225-227. 
Hutchinson,  W.   (211).     "The  Value  of  Pain."     Monist,  Chicago, 

1896-97,  vii,  494-504. 
Inman,  T.     "Letter  on  Inflammatory  Pain."     British  Med.  Jour., 

1858,  954-956;  1864,  ii,  359. 
.     "The  Nature  and  Cause  of  Neuritis  and  Pleurisy."     British 

Med.  Jour.,  1858,  242-244. 
,     "On  the    So-called   Hysterical   Pain."     British   Med.   Jour., 

1858,  24. 
Jacoby,  Geo.  W.  (474).     "Contribution  to  the  Study  of  Anesthetic 

Leprosy,   with    Special   Reference  to   Partial    Sense   Disorders." 

Jour.  Nerv.  and  Ment.  Dis.,  June,  1899,  xiv,  336. 
Jago,  J.    "Obscure  Trunk  Pains  or  Chronic  Pains  in  the  Abdominal 


BIBLIOGRAPHY  833 

and  Thoracic  Wall."     British  and  For.   Med.  and   Surg.  Rev., 

London,  1861,  xxvii,  490-502. 
Jakobson.     "Der  gegenwartige  Stand  unserer  Kenntniss  vom  Hirn- 

tumor."     Therapie  der  Gegenwart,  1909. 
James.     "Principles  of  Psychology."     Psychological  Review,  Sept., 

1894. 
Janet.    "Automatisme  psychologique."    Paris,  189-1. 
Janeway,  E.  G.   (568).     "Blood  Pressure."     I^ew  York. 

(513).     "The  Etiology  of  Pain."     Medical  Record,  May  29, 

1903. 

(107).  "Remarks  on  Some  Conditions  Simulating  Appendi- 
citis and  Periappendicular  Pain."  Medical  Record,  May  26, 
1900,  897. 

Janovsky^  V.  L.  "Intercostal  Neuralgia,  Principally  from  a  View- 
point of  the  Patient's  Symptoms."    Vrach.  Gaz.,  St.  Petersburg, 

1909,  xvi,  33,  62,  101,  137. 
.     "Tryzneni    ditete;   rnrt"    ("Severe    Pain   in    Child   Birth"). 

Casop.  lek.  cesk.  v.  Praze,  1885,  xxiv,  513-517. 
Jawger.     "Schwielenkopfschmerz."    J.  A.  M.  A.,  1909,  No.  17. 
Jessett^  Frederick  Bowman  (300).    "Discussion  on  the  So-called 

Ovarian  Pain,  Its  Causes  and  Treatment."    British  Med.  Jour., 

1904,  1059. 
Jessop,  Walter  (293,  634).    "Eye  Strain  as  a  Cause  of  Headache." 

Practitioner,  1906,  40-96. 
JoHRNEN    (866).      "Zur   Frage    der   Narkose   her   Ovariotomie   und 

Kaiserschnitt."     Centralblatt  fiir  Chir.,  1882. 
Johnson,  J.  C.    "Pathology  and  Diagnostic  Value  of  Pain."    Atlanta 

Med.  and  Surg.  Jour.,  1898-99,  N.  S.,  xv,  73-80. 
Johnston  (716,  721,  728,  732).    "Surgical  Diagnosis."    1st  ed.,  ii, 

402,  407,  420,  491. 
Johnstone,  H.  M.  (538).    "Nerves  of  Pleura."    British  Med.  Jour., 

Sept.  11,  1909,  686. 

(501).     "The  Nervous  System  of  Vertebrates."     Philadelphia, 

1906. 

.  "Notes  on  the  Distribution  of  the  Intercostal  Nerves."  Brit- 
ish Med.  Jour.,  1909,  ii,  685-686. 

Johnstone-Streeler.  "Anatomy  of  Vertebrates.  Drawing  of 
Nerves  in  a  Six-Weeks-Old  Embryo." 

JoTEYKO,  Mlle.  J.  (5,  50,  117,  443).  "Le  sens  de  la  douleur." 
Jour,  de  Neurol.,  Paris,  1905,  406,  493. 

— ■ — .  "Les  substance  algogenes."  Jour,  de  Neurol.,  Paris,  1905, 
X,  396-406. 


834  BIBLIOGRAPHY 

JoTEYKO,  Mlle.  J.    (514).     "Une  theorie  toxique  de  la  douleur." 
Eev.  gen.  de  sci.  pures  et  appl.,  Paris,  1906,  xvii,  No.  5,  240-243. 

and    Stefanowska,  Mlle.  M.     "Eecherches  algesimetriques." 

Acad.  roy.  de  Beige,  Bull,  de  la  cl.  de  sci.,  Bruxelles,  1903,  199- 
282. 

J.  A.   M.   A.     Discussion   on  abdominal   pain  by   various   authors. 

Lvi,  No.  21,  1606.   (Ab.) 

.     "Headache."     Therapeutic  section,  Ivii,  4,  282-283. 

.     "Pain  in  Abdominal  Diseases."     Sept.  24,  1910,  1132.   (300, 

ab.) 
Kast,  L.,  and  Meltzer,  J.  (1119).    "The  Abolition  of  Visceral  Pain 

by  Intramuscular  Injection  of  Coeain;  a  Demonstration."     Proc. 

Soc.  Exper.  Biol,  and  Med.,  N.  Y.,  1906-07,  iv,  97. 
(97).     "On  the   Sensibility  of  Abdominal  Organs  and 

the  Influence  of  Injections  of  Coeain  upon  It."     N.  Y.  Med. 

Eecord,  1906,  Ixx,  1017. 
Kealing  and  Coe  (739,  904).    "Gynecology."    1895,  831. 
Keay  (810).     "The  Seat  of  Pain  in  Biliary  Colic."     British  Med. 

Jour.,  1900,  i,  901. 
Keen  (745).     "System  of  Surgery,"  iii,  736. 

Kelly,  A.  0.  J.  (805,  809).     Osier's  "System  of  Medicine,"  v,  727. 
Kelly^  Howard  A.    (592).     "Abdominal  Pain."     Interstate  Med. 

Jour.,  February,  1911,  xviii,  No.  2,  194,  197. 

(349,  701,  717,  719).     "Gynecology,"  i,  29,  113,  587-589. 

.     "Sacroiliac  Pain."     Interstate  Med.  Institute.     Ab.  in  J.  A. 

M.  A.,  lvi.  No.  12,  885. 
Kennedy  (246).     "On  the  Eegeneration  of  Nerves."     Phil.  Trans. 

Eoy.  Soc,  1897,  clxxxviii,  series  B,  257. 
Kerr,  Le  Grand  (861).    "Abdominal  Pain  in  Infants  and  Children." 

Arch.  Diag.,  April,  1910,  iii,  2,  127. 
Kessel^  C.    "Gesammtorganismusleiden."    Zeitschrift  f.  Erfahrungs- 

heilkunde,  Berlin,  1849,  iii,  192-223. 
.     "Die  Krankheiten  des   Gesammtorganismus."     Zeitschrift  f. 

Erfahrungsheilkunde,  Eilenburg,  1848,  ii,  82-85. 
Kessler,  G.  L.  (41,  542,  552).    "Pain  and  Its  Treatment."    Brook- 
lyn Med.  Jour.,  1898,  xii,  661-671. 
Kiar.     "Et  Telfade  o   af  Brown-Sequard's  Lam  bed."     Hospital- 

stidende,  1892,  3  b.  x,  47.    Neurologisches  Centralblatt,  xii,  1893, 

863. 
KiEFFER  (546).    "De  la  douleur  en  gynecologic  obstetrique."    Presse 

med.  beige,  Bruxelles,  1907,  lix,  221-224. 
KiLGODR^  J.    "Observations  on  the  Pathology  and  Treatment  of  Pain, 


BIBLIOGRAPHY  835 

Especially  in  Plexus  and  Fibro-serous  Textures,"     Jour.  Med., 

London,  1851,  iii,  811-819. 
Killer,  Howard  E.    (450).     "Abdominal  Pain."     Interstate  Med. 

Jour.,  1911,  xviii,  No.  2,  191-197. 
KiLPE  (44).     "Outlines  of  Psychology." 
KiNNEMAN,  C.     "Hat  das  laute  Schreien  beim  Erdulden  von  kor- 

perlichen  Schmerzen  Einfluss  auf  deren  Linderung?"     Organ  f. 

d.  Gesammte  Heilkunde,  Aachen,  1856,  v,  164-167. 
KiRMissoN,  Prof.    "Les  formes  cliniques  de  la  scapulalgie."    Eevue 

gen.  de  clin.  et  de  therap.,  Paris,  1909,  xxiii,  758-760. 

(165).     "Clinical  Aspects  of  Scapulalgia."     Med.  Press  and 

Circular,  London,  Apr.  6,  1910. 

Klebs  (89).  "Pain  in  Tuberculosis  of  the  Lungs."  "Tuberculosis" 
(Appleton's,  1909),  222-223. 

Klesk,  a.  E.  (523).  "Studyum  bolu  fizycznego"  ("Study  of  Physi- 
cal Pain").     Przege  lik.,  Krakow,  1905,  xliv,  87-104,  119-133. 

Knowlton,  J.  W.  (166).  "Cause  and  Treatment  of  Headaches." 
Ala.  Med.  Jour.,  Birmingham,  Apr.,  1910,  200-210. 

KocHER  (401).  "Die  Verletzungen  der  Wirbelsaule  zugleich  als  Bei- 
trag  zur  Physiologic  des  mensclilichen  Eiickenmarkes."  Mitteil- 
ungen  aus  dem  Grenzgeb.  d.  Medizin  u.  Chir.,  1896,  i,  Heft  4. 

KoFMAN  (478).     Centralblatt  f.  Chir.,  1898,  40. 

KoHRSTAMM  and  Warnke  (278).  "Demonstrationen  zur  physiol- 
ogischen  Anatomic  der  Medulla  oblongata  (speziell  iiber  Leitung 
des  Temperatur)  und  Schmerzsinnes."  Deutsche  Zeitschrift  f. 
Nervenheilkunde,  1906,  xxxvi,  57. 

Krafft-Ebing.  "Nervositat  und  neurasthenische  Zustande,  in 
specieikr  Pathologic  und  Therapie  von  ISTothnagel." 

Krauss,  W.  C.  "A  Case  of  Cyst  Within  the  Spinal  Canal."  Brain, 
London,  1908,  xxx,  333-544. 

(586).     "Eine  praktisch  wichtige  Form  von  Sehnenzerrung." 

Zeitschrift  f.  Wundarzte  u.  Geburtshilfe,  1906,  Ivii,  18. 

.     "Subsequent  Eeport  on  a  Case  of  Severe  Spinal  Cord  Injury. 

Symptoms  of  Complete  Severance  of  the  Cord."    Annals  Surg., 

Philadelphia,  1907,  xlvi,  968. 
Krehi.  (534).     "Pathological  Physiology."    Am.  ed. 
Kreuzfuchs  (572).    "Angina  abdominalis."    Deutsche  med.  Woch., 

Feb.  17,  1910,  xxv.  No.  7,  306.    Ab.  in  J.  A.  M.  A.,  liv,  No.  13, 

1094. 
KiJLPE.     "Grundriss  der  Psychologic,"  93. 
KuLBiN,  N.     "Chuvstvitelnost  k.  prikosnovenigu  i  boli  normalnoye; 

rasprcdieleniye  ajeya  v  kozhie  chelovieka;  izsliedovaniya  proizve- 


836  BIBLIOGRAPHY 

dyonniya  posredstvom  esteziometru  artorce"  ("Sensation  to  Touch 
and  Pain  and  Its  Distribution  in  the  Human  Skin;  Investiga- 
tions Performed  by  the  Author's  Esthesioraeter').  Obozr. 
psichiat.  nevrol   (etc.),  St.  Petersburg,  1903,  viii,  927. 

KcrxDRAT  (360).  "Ueber  die  Austreibung  des  Carcinoms  in  para- 
metranem  Gewebe  bei  Krebs  des  Collum  uteri."  Archiv  f.  Gyn., 
Ixix,  355,  695. 

Kurtz,  C.  D.  (53).  "The  Diagnostic  Significance  of  Acute  Ab- 
dominal Pain."  Ohio  Med.  Jour.,  Columbus,  1908,  iv,  -477-480. 
Ab.  in  J.  A.  M.  A.,  Sept.  28,  1907,  xlix,  1138. 

KuTNER  and  Kramer.  "Sensibilitats  Storiingen  bei  acute  und  chron- 
ischen  Bulbarerkrankungen."  Archiv  fiir  Psychiatric,  1907,  xlii, 
1002. 

Laache,  S.  "Krankheiten  des  Blutes,"  in  Ebstein-Schwalbe's 
"Haudbuch  der  praktischen  Medizin."     Stuttgart,  1905,  i. 

(21-4).    "Zur  Lehre  von  den  Schmerzen  sogenannten  vascularen 

Ursprungs."    Deutsche  med.  Woch.,  Leipzig,  1894,  xx,  301-303. 

Laboxxe,  H.  "Comment  on  se  defend  de  la  douleur:  la  lutte  vic- 
torieuse  contre  la  souffrance  dans  la  plupart  des  maux."  Paris, 
1901. 

Lack^  H.  Lambert  (294,  633).  "Headache  of  Nasal  Origin."  Prac- 
titioner, 1906,  46-50;  1906,  48. 

Laehr.  "Ueber  Storungen  der  Schmerz-  und  Temperatur-Empfind- 
ungen  in  Folge  von  Erkrankungen  des  Eiickenmarkes."  Archiv 
f.  klin.  Med.,  xx,  158. 

La  Grifee,  L.  "Sommeil  et  douleur."  Toulouse  med.,  1901,  2,  iii, 
205-273. 

Lambert^  A.  "Misinterpretation  of  Cardiac  Pain."  Xew  York  State 
Jour,  of  Med.,  New  York,  Sept.,  1911. 

Lancereaux  (31,  387).    "Semaine  med.,"  1889,  229. 

Landois,  L.  "Anomalies  of  Pain."  "Physiology,"  ed.  1904,  Blak- 
iston,  934-935. 

.     "Conduction  of  Pain."      "Physiology,"  ed.  1904,  Blakiston, 

739-747. 

.     "Hysterical  Pain."     "Physiology,"  ed.  1904,  Blakiston,  936. 

(523,  541).     "Pain."     "Physiology,"  ed.  1904,  Blakiston,  934, 

935,  936. 

.     "Pain  Points."     "Physiology,"  ed.  1904,  Blakiston,  934. 

.     "Painful  Anesthesia."    "Physiology,"  ed.  1904,  Blakiston,  935. 

Lang  (610),  "Ueber  lanziuierende  Schmerzen  in  Bereicke  des 
Kopfes  bei  Tabes  dorsalis."  Wiener  kliu.  Woch.,  xxi,  Oct.  15, 
1908,  No.  42,  1438-1441.     Ab.  in  J.  A.  M.  A.,  li,  No.  22,  1913. 


BIBLIOGRAPHY  837 

Langdox,  F.  W.  (226).  "Pain  in  the  Back."  Lancet  Clinic,  Cin- 
cinnati, 1905,  liv,  121-124. 

Langley^  C.  W.  (131).  "The  Arrangement  of  the  Sympathetic  Ner- 
vous System,  Based  Chiefly  on  Observations  upon  Pilomotor 
Nerves.'"'     Jour.   Physiol.,   1893,  xv,   176-244. 

Langley,  J.  X.  (198).  "On  the  Larger  Medullated  Fibers  of  the 
S}Tnpathetic  System."    Jour.  Physiol,  1892,  xiii,  786. 

(199).     "On  the  Origin  from  the  Spinal  Cord  of  the  Central 

and  Upper  Thoracic  Sympathetic  Fibers,  with  Some  Observations 
on  White  and  Gray  Eami  Communicantes."  Phil.  Trans.  Roy. 
Soc,  1892,  B.,  85. 

(464).     "A     Short    Account    of   the     Sympathetic     System." 

Physiol.  Congress,  Berne,  1895. 

.      "The    Automatic    Nervous    System."      Brain,    1903,    xxvi, 

23. 

and  Sherixgtox,  C.  S.  (130).    "On  Pilomotor  Nerves."    Jour. 

Physiol.,  1891,  xii,  278. 

Lapixsky.  "Einige  wenig  beschriebene  Formen  der  Tabes  dorsalis." 
Deutsch.  Zeitschrift  f.  Nervenheilkunde,  1906,  xxx,  178. 

.     "Uebere  die  Herabsetzung  der  reflecktorischen  Vorgange  inx 

galahmten  Korperteil  bei  Kompression  der  oberen  Telle  des 
Eiickenmarkes."  Deutsch.  Zeitscht.  f.  Nervenhk.,  1906,  xxx, 
239. 

.     Ueber  den  Ursprung  der  Halssymphaticus  im  Eiickenmark. 

Deutsche  Zeitschrift  f.  Nervenheilkunde,  ix,  1901,  137-150. 

Laquer^  L.  (117).  "Ueber  Hirnerscheinungen  bei  heftigen  Schmer- 
zanfallen."  Archiv.  f.  Psychiatric,  Berlin,  1894,  xxvi,  818- 
827. 

La  Eoque,  G.  p.  (586).  "Diagnostic  Significance  of  Shock  Asso- 
ciated with  Acute  Abdominal  Pain."  Carolina  Med.  Jour.,  Char- 
lotte, 1906,  xiv,  145-150. 

(16).    "The  Diagnosis  of  Xffection  Characterized  by  Abdominal 

Pain."    N.  Y.  Med.,  1906,  Ixxxiii,  861-867. 

Lauexstein,  C.     "Zu  der  Frage  der  Bedeutung  des  Eovsing'schen 

Symptoms."     Centralblatt  fiir  Chirurgie,  Leipzig,  Aug.  5,  1911, 

1049. 
Lavraxd^  H.    (529).     "La  douleur."     Jour,  de  sci.  med.   de  Lille, 

1897,  ii,  497-500. 
Lee^  E.  H.     "Significance  of  Pain  in  Appendicitis."    Chicago  Clin., 

Oct.,  1900. 
Lehmaxx.    "Hauptgesetze  des  menschlichen  Gefiihllebens."  33, 
Lexx.'.::dee,  K.  G.  (230,  766).    "Beobachtungen  iiber  die  Sensibilifit 


838  BIBLIOGRAPHY 

in  der  Bauchhohle."  Mitteilungeu  aus  d.  Grenzgebiete  d.  Med.  u. 
Chir.,  Jena,  x,  Hefte  1  mid  2. 
Lennander,  K.  G.  (618,  7G0,  770,  958).  "Abdominal  Pain,  Espe- 
cially Pain  in  Connection  Avith  Ileus."  J.  A.  M.  A.,  Sept.  7, 
1907,  xlix.  No.  10,  437,  836-840;  Edinburgh  Med.  Jour.,  1907, 
xxii,  103-111. 

(87,  376,  586).    ''Leibschmerzen ;  oin  Vcrsuch  einige  von  ilmen 

zu   erklaren."      Mitteilungen   aus    d.    Grenzgebiete    d.    Med.    u. 
Chir.,  Jena,  1906,  xvi,  15,  19,  24-46. 

(548).     "Local  Anesthesia  in  l?egard  to  Sensibility  of  Organs 

and  Tissues."     Mitteilungen  aus  d.  Grenzgeb.  d.  Med.  u.  Chir., 
No.  45. 

(330).     "Observations    on    the    Sensibility    of    the    Abdominal 

Cavity."     London,  1903    (John  Bale  Sons,  and  Paulsson). 

■ (120,  180).     "Schmerzen  im  Bauch."     Archiv  f.  Verdauungs- 

krankheiten,  Berlin,   1907,  xiii.  No,   5,  463. 

(96).     "On  the  Sensibility  of  the  Abdomen."     Translated  by 

A.  E.  Barker. 

.    See  also  the  reference,  "Ueber  die  Sensibilitiit  der  inneren  Or- 


gane  von  Alfred  Neumann."  Centralblatt  fiir  die  Grenzgebiete, 
1910,  xiii. 

(1155).     "Smartor  i  buken,  ett  forsok  att  forklara  nagra  af 

dem."  (Leibschmerzen,  ein  Versuch  einige  von  ihnen  zu 
erklaren.)  Upsala,  Liikaref,  Forli.,  1904-05,  n.  f.  x,  465-492. 
Transl.,  556. 

Lerrington.  "Experiments  in  Examination  of  the  Peripheral  Dis- 
tribution of  the  Fibers  of  the  Posterior  Eoots  of  Some  Spinal 
Nerves."     Phil.  Trans.  Eoy.  Soc,  London,  xxxvii,  641. 

Leszynsky  (498,  550).  "Circumscribed  Motor  Paralysis  and  Cu- 
taneous Anesthesia  Following  Injury  of  the  Cerebral  Cortex." 
N.  Y.  Med.  Jour.,  Apr.  30,  1910,  893. 

Lett,  J.  "Facial  Neuralgia  in  Eelation  to  Almormal  Oral  Condi- 
tions."    Dental  Cosmos,  Philadelphia,  1908,  458-461. 

Leube.  Section  on  pain  sensations  in  "Spezielle  Diagnose  der  inneren 
Krankheiten."     Leipzig. 

Levy,  F.  "Diagnostic  des  neuralgies  faciales."  Presse  med.,  Paris, 
1909,  xvii,  419. 

Lewandowsky  (398).  "Die  Funktionen  des  centralen  Nervensys- 
tems."     Jena,  1902,  187. 

Lewin  and  Boer  (468).  "Quetschungen  und  Ausrottung  des 
Ganglion  coeliacum."     Deutsche  med.  Woch.,  1894,  217. 

Leyden.     "Klinik  der  Riickenmarkskrankheiten." 


BIBLIOGRAPHY  839 

Leyden  and  Goldscfieidee.     '^'Die  Erkrankungen  des  Eiickenmarkes 

und  der  Medulla  oblongata."     Vienna,  1895. 
LiCHTENSTEiN^  Hermine.    "Demonstration  einer  Kranken  mit  Kom- 

pressions    Myelitis    und    ganz    atypischer    Sensibilitatsstorung." 

Mitteilungen  d.  Gesellschaft  f.  Med.  u.  Kinderk.,  Wien,  1909, 

viii,  4-7. 
LiCKLEY,  J.  D.     "Visceral  Pain."     Univ.  Dublin  Coll.  Med.  Gaz., 

1907-08,  viii,  123. 
Lloyd.     "Spinal  Localization."     J.  A.  M.  A.,  is.  No.  23,  1885. 
LocKWOOD,  B.  C.  (830).     Lancet,  Mar.  4,  1905. 
LocEYER^  C.  (307).    "Discussion  on  the  So-called  Ovarian  Pain,  Its 

Causes  and  Treatment."    British  Med.  Jour.,  1904,  10G2. 

(1025).     "The  Value  of  Pain  in  Gynecologic  Practice."    Prac- 
titioner, London,  1905,  Ixxv,  358-373. 

LoEB,  Jacques.     "Comparative  Physiology  of  the  Brain."     London, 

1905   (John  Murry). 
LoEWENTHAL,  Max  (532).    "Effect  on  Conductivity  of  Spinal  Cord 

from  Compression  of  the  Aorta."    Brain,  xxv,  274. 
LOFEER,  W.  B.    "Diagnosis  of  Tumors  of  the  Cord."    Ohio  Med.  Col. 

Jour.,  1908,  iv,  700-704. 
LoLLEY,  J.  (4).    "The  Medical  Treatment  of  Abdominal  Pain  JSTot  of 

Gastric  Origin."    Medicine,  1906,  ii,  57-GO. 
LoMER,  EiCHARD   (257,  321).     "Beurtheilung  des  Schmerzes  in  der 

Gynakologie."    Wiesbaden,  1899. 

(147).     "Gynakologie."    1889. 

LooMis,  A.  L.     "Pain  as  a  Symptom  of  Disease."     Med.  Eecord, 

N.  Y.,  1873,  viii,  473. 
LoRTAT^  Jacob  L.,  and  Sabareanu^  G.    "Les  sciatiques  radiculaires." 

Eev.  de  med.,  1905. 

(602).      "Sur    les    sciatiq^^es    radiculaires    racines    le 

plus  frequemment  prises."     Tribune  medical,   Paris,   1908,  xl, 
581. 

.     "Sciatique  radiculaire  unilaterale."     Presse  med.,  Oct. 

5,  1904. 
Lourbet,  J.     "La  douleur  et  I'intelligence."     Eev.  sci.,  Paris,  1897, 

iv,  vii,  751-753. 
LovETT^   John    Morse    (112,    494).     Annals    of    Gynecology    and 

Pediatry,  Nov.,  1899,  143. 
LuDLUM,  S.  D.     "The  Eelationship  Between  the  Spinal  Cord,  the 

Sympathetic  System  and  Therapeutic  Measures."    J.  A.  M.  A., 

1908,  i,  1401-1405. 
Lussana^  F.     "De  dolore  qual  funzione  propria  al  medollo  spinale 


840  BIBLIOGRAPHY 

et  distinta  del  senso."     Gazz.  med.  ital.  lombo.,  Milano,  1864, 

5,  iii,  233. 
LussANA,  F.,  and  Morganti,  G.     "Sulla  sede  della  addolorabilita." 

Ann.  univ.  di  med.,  Milano,  1855,  cliv,  342. 
Lyman  (944).     "Epigastric  Pain  as  a  Symptom."    Univ.  Col.  Med. 

Bull.,  Bowlder,  190G-07,  iii,  Xo.  2,  81-85. 
MacClean,  J.  EwEN  (304).     "Discussion  on  the  So-called  Ovarian 

Pain,  Its   Causes  and  Treatment."     British  Med.  Jour.,   1904, 

1060. 
MacCrae,  F.     "Abdominal  Pain  in  Typhoid."     N.  Y.  Med.  Jour., 

May  4,  1901. 
McCrae   (607).     "Typhoid  Fever."     Osier's  "System  of  Medicine," 

i,  159. 
MacCullen,  J.  H,     "Pain,  Its  Beneficent  Use  as  Means  of  Allura- 

tion."     Dental  Cosmos,  Philadelphia,  1865-66,  vii,  631-635. 
MacDoxald,  Archus   (29).     "Measurement  of  Pain."     Eeview  of 

works  of  A.  MacDonald,  British  M.  and  S.,  1899,  cxl,  146. 
MacDougal.    "The  Nature  of  Inhibitory  Processes  Within  the  Ner- 
vous System."     Brain,  1903,  xxvi,  153-192. 
MacEwen,  J.  A.  C.    (119).     "Case  of  Intraparietal  Hernia  with  a 

Very  Small  Peritoneal  Opening  Giving  Rise  to  Severe  Abdominal 

Pain."    Lancet,  Oct.  19,  1907,  1081. 
MacGarrahan,  J.  F.    (18).     "Some  Conditions  Having  as  Symp- 
toms Pain  and  Tenderness  in  the  Right  Iliac  Region."     Albany 

Med.  Annals,  1905,  xxvi,  719-724. 
Mackenzie,  J.    (77).     Med.  Chronicle,  1892,  xvi,  295. 
.     "Associated  Pains  of  Visceral  Diseases."     Caled.  Med.  Jour., 

Rochester,  1891,  4,  i,  39-45. 

(140,  162,  232,  325,  575,  586,  752,  769,  791,  796,  862).     "The 

Meaning  and  ]\Iechanism  of  Visceral  Pain."  British  Med.  Jour., 
June  30,  1906,  i,  1325,  1449-1452,  1523-1528. 

■ .      (225,   296).      "Nature   of   the    Symptoms   in   Appendicitis." 

British  Med.  Jour.,  July  11,  1903,  66-68. 

(33).     "Pain."    Brain,  London,  1902,  xxv,  368-387. 

.     "The  Pilomotor  of  Goose-skin  Reflex."    Brain,  1893,  iii,  515. 

■ (2,  76,  574,  833).     "Remarks  on  the  Meaning  and  Mechanisms 

of  Visceral  Pain  as  Shown  by  the  Study  of  Visceral  and  Other 
Sympathetic  (Autonomic)  Reflexes."  British  Med.  Jour.,  Lon- 
don, June  23,  1906,  i,  1449-1454. 

(69,  332,  762).     "Some  Points  Bearing  on  the  Association  of 

Sensor)^  Disorders  and  Visceral  Disease."  Brain,  1893,  xvi.  part 
III,  321-343. 


BIBLIOGRAPHY  841 

Mackenzie,   Kenneth  B.    (599).     "Eesection   of   Sciatic  Nerve." 

Surg.  Gyn.  and  Obst.,  July,  1909,  30-41. 
MacWith.     "Some  Peculiarities  of  Pelvic  Pain."     Brooklyn,  N.  Y., 

1903,  xvi,  515-517. 
Malaise,   E.    V.      "Ueber    die    diaguostische    Wertung   halbseitiger 

Krampfe."      Miinchener    med.    Wochensch.,    Jan.    9,    1913,    lix, 

No.  2,  81. 
Mann.     "Casuistischer  Beitrag  zur  Lehre  von  central  entstehenden 

Schmerzen."     Berliner  klin.  Woch.,  1893,  ii,  344. 
Mansell,  C.  W.    (578).     "Causes  of  Pain  in  Gastric  Ulcer,  etc.'' 

Lancet,  Mar.  4,  1905,  565. 
Mantegazza,  p.  (536).     "Phys.  de  la  doleus."     Chap.  X. 
.     "Deir  azione  del  dolore  sulla  calorificazione  e  sui  moti  del 

cuore."     Gazz.  med.  ital.  lomb.,  Milano,  1866,  5,  v,  333,  343, 

249,  355. 
.     "Dell'  azione  del  dolore  sulla  digestione  e  sulla  metrizime." 

Gazz.  med.  ital.  lomb.,  Milano,  1871,  6,  iv,  45-53.. 
.     "Deir  azione  del  dolore  sulla  respirazione."     Gazz.  med.  ital. 

lomb.,  Milano,  1867,  5,  vi,  385,  405,  413,  425. 
.     "Deir  espressione  del  dolore."    K.  S.  Lombard,  sc.  e  lett.  E., 

Milano,  1874,  3,  vii,  154-163. 
.    "Espressione  del  dolore  secondo,  il  sesso.  I'eta,  la  constituzione 

indivuale  e  la  rozza."    Gazz.  med.  ital.  lomb.,  Milano,  1878,  7,  v, 

301,  313. 
Marburg,  0.   (531).     "Drawings  of  Pathways  in  Cord  and  Brain." 

Found  in  Atlas  of  Nervous  System,  Wien,  1904. 
.     "Ueber  die  neueren  Fortschritte  in  der  topischen  Diagnostik 

des  Pons  und  der  Oblongata."    Deutsche  Zeitschrift  fiir  Nerven- 

heilklinde,  1911,  xli,  41. 
Marcus,  H.  D.     "Pain  in  Disease."     Gaillard's  Med.  Jour.,  N.  Y., 

1843,  Ivi,  579-581. 
Marestand.     "Contribution  a  I'etude  du  diagnostique  de  la  lepre 

anesthetique  et  de  la  syringomychi."     Eev.  de  med.,   1891,  xi, 

781. 
Maeey,     "Da  la  claudication  par  douleur."     Compt.  rend.  acad.  de 

sci.,   Paris,   1888,   cvii,   641-643.;  France  med.,   Paris,   1888,   ii, 

1565-1567;  Gaz.  med.  de  Paris,  7,  v,  517. 
Marogna,  p.    "Un  caso  di  algia  dello  sciatica  da  cisti  di  echnococco." 

Gazz.  d.  osp.,  Milan,  1908,  4,  xiv,  150-153. 
Marot.     Bulletin  de  la  societe  anatomique,  1875. 
Marshall,  H.  E.  (130,  601).    "Are  There  Special  Nerves  for  Pain?" 

Jour.  Nerv.  and  Ment.  Dis.,  N.  Y.,  Feb.,  1894,  xxi,  71-84, 


842  BIBLIOGRAPHY 

Marshall,  H.  R.  "Criticism  on  NichoFs  'Pleasure  and  Pain.'  "    Phil. 

Review,  vi.  No.  1. 

.     "Pain,  Pleasure,  and  Esthetics."     London,  1894. 

(8).    "Physical  Pain."    Physiol.  Eev.,  N.  Y.  and  London,  1895, 

ii,  6,  594-598. 

(511).     "Pleasure  and  Pain,"  25. 

.     "Pleasure,  Pain."    Mend.  N.  S.,  iii,  533-535.  ' 

Martens.     "Die  Erkennung  und  Behandlung  der  Perforations  Peri- 
tonitis."    Med.  Clin.,  1908,  No.  49,  1857. 
Martin^  Gil.    "El  meccanismodel  dolor  abdominal."    Rev.  ibero-am. 

de  cien.  med.,  Madrid,  1907,  xviii. 
Martius  (445).    "Der  Schmerz."    Wien  and  Leipzig  (F.  Deuticke), 

1898,  No.  24,  80. 
Massalongo  (490).     "Topographica  L.  Mecolai,"  275. 
Masselon  (117).    "Les  reactions  affectives  et  I'origine  de  la  douleur 

morale."     Jour,  de  psychol.  et  pathol.,  Paris,  1905,  ii,  496-513. 
Mattirolo,  G.     "Pain  of  Central  Origin."     Rioforma  Medica,  July 

31,  1911. 
Matzinger,  H.  G.  (284,  328).     "A  Study  of  the  Origin  and  Nature 

of  Pain."    Buffalo  Med.  Jour.,  1895-96,  xxxv,  137-144. 
May,  p.     "Ueber  sensorische  Nerven  und  periphere  Sensibilitaten." 

Ergebnisse  der  Physiologic,  Wiesbaden,  1909,  viii,  651-697,  4  pi. 
Maylard  (705,  726,  734,  748,  812,  828).     "Abdominal  Pain,"  82, 

97,  101,  106,  110. 
Maylard,  Ernest  (322,  535,  1268).     "Abdominal  Pain,  Its  Causes 

and  Clinical  Significance."     Philadelphia,  1905   (P.  Blakiston's 

Son  and  Co.)  ;  I^ondon,  2d  ed.  (J.  and  A.  Churchill),  315. 
Mayo,  T.  J.     "The  Therapeutics  of  Pain."     Philadelphia  Polyclin., 

1892,  ii,  24-32. 
Mayr,  M.     "Disputatio  medica  de  dolore."     Ingolstadt,  1615. 
McEwitt  (914).     Brooklyn  Med.  Jour.,  1902,  xvi,  515-517. 
Meade   (503).     Am.  Jour.  Physiol.,  1893-95.     Quoted  by  Bianchi, 

345. 
Melciiior,  Ed.     "Ueber  perityphlitische   Symptome    (Pseudoappen- 

dicitis)  in  Beginne  der  Pneumonic,"  xx,  469. 
.     "Ueber  einen  autoptisch  •  verifizierten   Fall  von  tuberkulosem 

Gelenkrheumatismus,"  xxii,  346. 
Meltzer,  S.  J.     "Bemerkungeu  iiber  Gastralgie,  Morgenkolik  und 

Kolik  im  Allgemeinen."     Archiv.  f.  Verdauungs  Krankheiten, 

ix,  450,  1903. 
Melville,  E.  J.     "The  Relief  of  Pain."     Vermont  Med.  Monthly, 

Burlington,  May  25,  1901. 


BIBLIOGRAPHY  843 

Menge  (345).  "Das  Wesen  der  Dysmenorrhoea."  Centralblatt  f. 
Gynakologie,  1901,  No.  1. 

Mettler.  "The  Eelative  Importance  of  Symptomatic  and  Physiolog- 
ical Diagnosis  in  Neurology."  Archive  Diag.,  N.  Y.,  1908,  i, 
9-18. 

(469,  505).  "Syringomyelia;  Sensory  Dissociation  as  a  Symp- 
tom."   J.  A.  M.  A.,  1908,  1,  No.  6,  436-439. 

Meuniee^  L.    "Un  symptome  clinique  de  I'ulcere  duodene-pylorique." 

Presse  med.,  Paris,  Feb.   7,  1912,  xx,  No.   11.     Ab.  in  J.  A. 

M.  A.,  Mar.  16,  1912,  Iviii,  11,  821. 
Meyer,  S.   (81).     "Der  Schmerz.     Eine  Untersuchung  der  psycho- 

logischen    und    physiologischen    Bedingungen    des    Schmerzvor- 

ganges."    Wiesbaden,  1906  (J.  F.  Bergmann). 
Meyers,  Jerome  (122,  152,  239,  1008).    "The  Seat  and  Significance 

of  Abdominal  Pain."    Albany  Med.  Annals,  1907,  xxviii,  No.  9, 

456,  744-753. 
Meynert.     "Psychiatric."      (A   clinical   treatise   on   the   forebrain, 

based  upon  a  study  of  its  structure,  functions  and  nutrition.) 

1884,  163. 
MiCHAELis,  Ad.  (965).    "Der  Schmerz.    Ein  wichtiges  diagnostisches 

Hilfsmittel.     Eine  Schmerz-Theorie."     Leipzig,  1905. 
MiLiAN,  G.    "Pain  in  the  Side  in  Habitual  Drinkers."    Presse  med., 

Apr.  18,  1900. 
Miller,    Morris    Booth    (725).      "Perinephritic    Abscess."      An- 
nals of  Surgery,  li,  No.  3,  382-415  (see  392). 

.     Deutsche  Aerztezeitung,  1910,  Heft  3. 

Mills,  C.  K.    "New  Symptom-Complex  Due  to  Lesion  of  Cerebellum 

and  Cerebro-rubro-thalmic  System."     Jour,  of  Nerv.  and  Ment. 

Dis.,  Feb.,  1912,  xxxix.  No.  2. 
Milner.     "Hyperalgetische  Zonen  bei  Kopfschiissen."    Berliner  klin. 

Woch.,  1904,  No.   17. 
Mitchell,  John  K.    (155,  238,  767,  840).     "Local  Anesthesia  in 

General  Surgery."     J.  A.  M.  A.,  1907,  xlix,  198-201,  204. 
Mitchell,  S.  W.   (30,  294,  559).     "Wrong  Eeference  of  Sensation 

of  Pain."     Med.  News,  Philadelphia,   1895,  Ixvi,  No.   2,  281; 

Med.  Eecord,  Dec.  24,  1892. 

(263).  "Injuries  of  Nerves  and  Their  Consequences."  Phila- 
delphia, 1872  (Lippincott). 

(273).     "A  Pare  Vasomotor  Neurosis."    Am.  Jour.  Med.  Sci., 

July  17,  1878. 

Mitchell,  W.  Morehouse,  and  Keen.  "Gunshot  Wounds  and 
Other  Injuries  of  Nerves."     Philadelphia,  1864. 


844  BIBLIOGRAPHY 

MoBius    (459).      "Allgemeine   Diagnostik   der   Nervenkrankheiten." 

2te  Auflage,  192. 

.     "Der  Kopschmerz."     Halle,  1902. 

.     "Die  Migraine"  in  H.  JSTothnagel's  "Specieller  Pathologie  und 

Therapie."    Wien  (Holder). 
MoJON,  J.  B,     "Suir  utilita  del  dolore.  Discorso  accademico  letto 

alia  societa  medica  d'emulazione."    Genoa,  1811. 
MoLEEN,  Geo.  A.  (778,  783).    "Diseases  of  Cerebral  Arteries."  J.  A. 

M.  A.,  Feb.  27,  1909,  1,  No.  9,  678. 
MoNAKOW,  VON.     "Neue  Gesichtspunkte  in  der  Frage  nach  der  Lo- 

kalisation  im  Grosshirn."    Corr.-Blatt  f .  schweiser  Aerzte,  Basel, 

1909,  xxxix,  401-415,  1  pi. 
Monro  (556).     Glasgow  Med.  Jour.,  vi,  No.  1,  11. 

(789).    "Disorders  of  Digestion,"  108,  109.    Quoted  by  Lauder 

Brunton. 

Monro,  T.  K.  (31,  135).  "A  Case  of  Sympathetic  Pain;  Pain  in 
Front  of  the  Chest  Induced  by  Friction  of  the  Forearm."  Brain, 
London,  1895,  xviii,  566-570,  1  pi. 

(32,  236,  788).  "Sympathetic  Pains,  Their  Nature  and  Diag- 
nostic Value." .  Glasgow  Med.  Jour.,  1898,  1,  1-12. 

Monteverdi,  A.     "Sul  dolore,  fondamento  della  pathologia."     Gazz. 

med.  ital.  lomb.,  Milano,  1861,  4,  vi,  281-283. 
Morales.    "Semeiotica  del  dolor  provocado  en  algunas  enfermedades 

del  aparato  digestivo."     Madrid,  1904,  li,  608-610,  622. 
Moras,  E.  E.   (34,  176).     "A  Plea  for  Pain  and  Patient."     Boston 

Med.  and  Surg.  Jour.,  1901,  cxlv,  708. 
Morgan,  Snauther   (315).     "Discussion  on  the  So-called  Ovarian 

Pain,  Its  Causes  and  Treatment."     British  Med.  Jour.,  1904, 

1063. 
Morris.     "Errors  Made  in  Two  Hundred  and  Twenty-eight  Cases 

Diagnosticated  as  Appendicitis."    N.  Y.  Med.  Jour.,  Ixix,  1899, 

469. 
Morris,  Henry.    (426).     "Eeflex-renorenal  Pain."     "Surgical  Dis- 
eases of  Kidneys  and  Ureters,"  ii,  1901,  84. 
Morris,  Port.  P.  (834).    J.  A.  M.  A.,  Jan.  25,  1908. 
Morris,  Eobt.  T.   (591,  834).     "McBurney's  and  Another  Point  in 

Appendix  Diagnosis."    J.  A.  M.  A.,  Jan.  25,  1908. 
Morton,  C.  A.   (104).     "The  Diagnosis  and  Causes  of  Acute  .^'- 

dominal  Pain."    Clin.  Jour.,  London,  1903-04,  xxiii,  232-236. 
Morton,  E.  E.    "Painful  Heels."    Lancet,  London,  1909,  ii,  223. 
Mortyn,    S.      "On   the    Physiological    Meaning   of    Inframammary 

Pain,"  296-298. 


BIBLIOGRAPHY  845 

MossE^  M.     "Ueber  den  Kreuzschmerz."     Therapie  d.   Gegenwart, 

Berlin,  1904,  xlv,  549-551. 
MoTT,  F.  W.  (431).    "Experimental  Inquiry  upon  the  Afferent  Track 

of  the  Central  Nervous  System  of  the  Monkey."     Brain,  1891 

and  1895,  219. 

.   (417,  429).     Brain,  1893,  1. 

.     "Experimental  Inquiry  upon  the  Afferent  Tracts."     Brain, 

xviii,  1895,  1. 
.     "Hemisections  Made  at  Different  Levels  in  the  Dorsal  Ee- 


gions  of  the  Monkey."    Jour,  of  Physiol.,  xii,  iii. 

(193,  918).    "The  Physiology  of  the  Emotions."    British  Med. 

Jour.,  Apr.  4,  1908,  791. 

(197).     "Sensory  Visceral   Fibers."     Jour.  Anat.   and  Phys., 

xiii,  1892. 

MouLLiN,  C.  W.  "A  Clinical  Lecture  on  the  Early  Diagnosis  of  Ulcer 
of  the  Stomach."    Lancet,  Sept.  22,  1900. 

(46,  792).    "The  Cause  of  Pain  in  Cases  of  Gastric  Ulcer  and 

Its  Bearing  upon  the  Operation  of  Gastro-jejunostomy."    Lancet, 
Mar.  4,  1905,  565. 

(226,  297,  765,  839).     "Significance  of  Pain  and  Tenderness 

in  Cases  of  Inflammation  of  the  Appendix."     Lancet,  Aug.  22, 
1903,  514-515. 

MtJLLER  (224,  295).  "Head'sche  Zonen  bei  chirurgischen  Abdom- 
inalerkrankungen."     Centralblatt  f.  Chirurgie,  1903,  No.  2,  54. 

MtJLLER,  A.,  and  Heezog  (128).  "Omarthritis  mit  Brachialgie  und 
Behandlung."  Therapeutische  Monatshefte,  Feb.,  1910,  xxiv, 
90-93. 

MtJLLER^  Ed.  "Zur  Symtomatologie  und  Diagnose  der  Stirnhirn- 
geschwiilste."  Deutsche  Zeitschrift  f.  Nervenheilkunde,  1902, 
xxii,  5,  6. 

MuLLER,  Friedrich.  "Dentaler  Stirnkopfschmerz."  Miinchener  med. 
Woch.,  1909,  No.  5. 

MiJLLER,  J.  B.  "Abhandlung  iiber  verschiedene  Krankheiten,  welche 
urspriinglich  aus  einer  Scharfe  entstehen,  also  verschiedene  Haut- 
krankheiten,  Skrofeln,  Lustseuche,  Krebs  und  Gicht  nebst  heir 
gefiigter  Heilart  und  den  bewahrtesten  Eecepten."  Frankfurt, 
1796. 

MtJLLER^  L.  R.  "Ueber  die  Empfindungen  in  unseren  inneren  Or- 
ganen."    Mitteilungen  aus  den  Grenzgebieten,  1908,  xviii. 

Mulls  and  Weisenberg  (444,  551).  "The  Subdivision  of  the  Repre- 
sentation of  Cutaneous  and  Muscular  Sensibility  and  of  Stereog- 


848  BIBLIOGRAPHY 

nosis  in  the  Cerebral  Cortex."    Jour.  ISTerv.  and  Ment.  Dis.,  Oct., 

1906,  xxxiii,  26. 
MiJNSTERBERG.     "Liist  mul  Unlust."     Beitrage  zur  experimentellen 

Psychologic,  No.  4. 
Murdoch,  F.  H.  (19,  336).     "The  Clinical  Significance  of  Pain  in 

the  Epigastrium."     Med.  News,  1904,  Ixxxiv,  538-541. 
MuRDOCK  (627).  "Addison's  Disease."  Med.  News,  Mar.  19,  1904,  54. 
Murphy,  J.  B.  (816).    Year  Book  Series,  1907,  ii,  503. 

(518).     "Embolus  of  External  Iliac."     J.  A.  M.  A.,  May  22, 

1909. 

(369).     "Surgery  of  Spinal  Cord."    J.  A.  M.  A.,  1907,  xlviii, 

765-774. 

Murray,  Montague  H.    (249).     "Acute  Pneumonia  in  Children." 

British  Med.  Jour.,  June  8,  1907,  1345-1350. 
MuRRi.    "Le  sintoma  dolore  nelle  diagnosi  difficili  all  indeterminate." 

Eiv.  crit.  di  clin.  med.,  Firenze,  1901,  ii,  287,  313,  329,  349; 

Bull,  di  clin.,  Milano,  1901,  xviii,  385-405. 
MussER,  J.  H.    (20,  159,  235,  324,  433,  746,  938).     "Abdominal 

Pain."    Am.  Med.,  Philadelphia,  Mar.  26,  1904,  vii,  503-505,  573. 
• (5,  374,  424,  558,  587).     "Pain  of  Obscure  Origin  Simulating 

Neuritis,   Neuralgia   or    Organic   Lesions."     Penn.    State   Med. 

Jour.,  Athens,  1905-06,  ix,  350-352. 
Nast-Kolb  (853).     "Beitrag  zur  Frage  der  Sensibilitat  der  Bauch- 

organe."     Centralblatt  f.  Chir.,  1908,  No.  28. 
Natanson.     "Analyse  der  Functionen  des  Nervensystems."     Archiv 

f.  physiol.  Heilkunde,  Stuttgart,  iii. 
Naunyn,  B.    "Der  Diabetes  mellitus"  in  H.  Nothnagel's  "Specieller 

Pathologie  und  Therapie."     Wien  (Holder). 
.     "Ueber  die  Auslosung  von  Schmerzempfindung  durch  Sum- 
mation sich  zeitlich  folgender  sensibler  Erregungen;  ein  Beitrag 

zur    Physiologic    des    Schmerzes."      Archiv    f.    exper.    Path.    u. 

Pharmak.,  Leipzig,  1888-89,  xxv,  272-305. 

(565).  "Ueber  cine  eigenthiimliche  Anomalie  der  Schmerzemp- 
findung."   Archiv  f.  Psychiatric,  Berlin,  1873-74,  iv,  760-762. 

Neuman,  Alfred.  "Ueber  die  Sensibilitat  der  Innerer  Organe." 
Centralblatt  fiir  die  Genz.  d.  Med.  u.  Chir.,  xiii.  No.  401,  1910. 

.     "Schmerzen   bei    Erkrankungen    des    Centralnervensystems." 

Wien  (Edlach). 

Newman,  David  (427).  "Eenorenal  Eeflex."  "Diagnosis  of  Sur- 
gical Diseases  of  Kidney,"  71. 

Nichols  (81,  82).  "The  Origin  of  Pleasure  and  Pain."  Philo- 
sophical Review,  i,  Nos.  4  and  5. 


BIBLIOGRAPHY  847 

Nichols.  "Pain  Nerves."  Psycholog.  Eeview,  1896,  iii.  No.  3,  SOD- 
IS. 

NiEDEN  (259).  "Ueber  Perinephritis  haiiptsachlich  in  atiologischer 
unci  diagnosticher  Bcziehimg."  Deutsches  Archiv  f.  klin.  Med., 
1878,  xxii,  498. 

Norman,  W.  W.  (7,  73).  "Diirfen  wir  aus  den  Eeactionen  niederer 
Tiere  auf  das  Vorhandensein  von  Schmerzempfindungen  schlies- 
sen?"  Archiv  f.  d.  gesamrate  Physioh,  Bonn,  1897,  Ixvii,  137- 
140;  Am.  Jour.  Physiology,  Boston,  1899-1900,  iii,  270-284. 

NoRSZEWSKi,  K.  "Czucin  odprzedmiotowe  bol  i  paradoksalny  alge- 
simeter"  ("Objective  Sensation,  Pain  and  the  Algesimeter"). 
Now.  lek.,  Poznan,  1900,  xii,  507-511. 

NoTHNAGEL   (233).     Archiv  f.  Verdauungskrankheiten,  ii,  117-132. 

.     "Beitrage  zur  Physiologic  und  Pathologic  des   Temperatur- 

sinns."    Deutsches  Archiv  f.  klin.  Med.,  1867,  ii,  284. 

.     "Die    Erkrankungen    des    Darmes    und    des    Peritoneums.'' 

"Specieller  Pathologic  und  Therapie,"  "Wien  (Holder). 

.     "Krankheiten  des  Gehirns."    "Topische  Diagnostik." 

.  "Zur  Pathogenese  der  Kolik."  Archiv  f.  Verdauungskrank- 
heiten, 1905,  xi,  2. 

.     "Sehmerz    und    cutane    Sensibilitatsstorungen."      Archiv    f. 

Path.,  Anat.,  etc.,  Berlin,  1872,  liv,  121-136. 

Novak,  E.  (117,  143,  905).  "Pain  in  Pelvic  Disease."  Am.  Jour. 
Obst.,  Apr.,  1908,  Ivii,  175. 

Obersteiner  and  Eedlich.  "Krankheiten  des  Riickenmarkes." 
Ebstein-Schwalbe's  "Handbuch  der  praktischen  Medizin,"  Stutt- 
gart, 1905. 

Obraztsoff,  V.  P.  "Operenosie  transferentni  bolevikh  oshtshreshtche- 
nij  V  Bryushnoi  polosti"  ("Transference  of  Painful  Sensations 
in  the  Abdominal  Cavity").  Bolnitsch  Gaz.  Botkina,  St.  Peters- 
urg,  1900,  xi,  185-237. 

Oefele,  von  (587).  "Welche  Stelle  soil  mit  Trubschem  Apparate 
behandelt  werden?"    Deutsche  med.  Presse,  Berlin,  1906,  x,  41. 

Olvera,  J.  (833).  "Que  valor  tiene  el  dolor  comeo  signo  para  el 
diagnostico  de  las  enfermedades  de  los  organos  del  vientre."  Gaz. 
med.  de  Mexico,  1906,  iii,  3,  i,  97-107. 

Oppeniieim.  "Die  Encephalitis  und  der  Gehirnabscess,"  in  H.  Noth- 
nagel's  "Specieller  Path.  und.  Therapie,"  Wien  (Holder). 

.    "Die  Geschwiilste  des  Gehirns."     See  above. 

.     "Die  syphilitischen  Erkrankungen  des  Gehirns."     See  above. 

.     "Lehrbuch  der  Nervenkrankheiten,"  Berlin,  1908   (Karger). 

Oppeniieim,  H.  "Zur  Psychotherapie  der  Schmerzen."  "Therapie 
der  Gegenwart,"  Berlin-Wien,  1900,  ii,  108. 


848  BIBLIOGRAPHY 

Oppenheimer,  Z.    "Schmerz-  und  Temperaturempfindung,"    Berlin, 

1895. 
Ormerod,  J.  A.    "A  Clinical  Lecture  on  Acroparesthesia."     Clinical 

Jour.,  London,  1908,  xxxii,  1-4. 
Ortumo,  E.  M.    "El  dolor."    Mexico,  1844. 
OsLER  (747).    "Polyuria  and  Abdominal  Pain."    Assoc.  Am.  Phys., 

rep.  Med.  News,  May  14,  1904,  950. 

(892).     "Angina  Pectoris."    Lancet,  Mar.  26,  1910. 

(109).     "A  Plea  for  the  More  Careful  Study  of  the  Symptoms 

of  Perforation  in  Typhoid  Fever,  with  a  View  to  Early  Opera- 
tion."   Lancet,  Feb.  9,  1901,  i,  386. 

(108).     "Practice  of  Medicine."    4th  ed.,  117. 

OsTHOFF.  "Die  Verlangsamung  der  Schmerzempfindung  bei  Tabes." 
Dorsal's  "Dissertation,"  Erlangen,  1894. 

OsTROM,  H.  D.  (178).  "Significance  of  Pain  in  Gynecologic  Diag- 
nosis."   Jour.  Surg.  Gyn.  and  Obstet.,  N".  Y.,  1905,  xxvii,  9-23. 

Ottolenghi,  S.  (449).  Centralblatt  f.  Nerv.  u.  Psych.,  No.  7.  Ab. 
in  J.  A.  M.  A. 

.     "La  misura  del  dolore,  coll'  algesimetro  del  Cheron  e  cogli 

elletro-algesimatori.  Osservazioni  sperimentale  di  semeiotica  med- 
ico formale."  Att.  d.  cong.  internat.  di  fisiol.,  Eoma,  1906,  i, 
640-652. 

Pace  (743).     Med.  Eecord,  June  8,  1908. 

Pace,  E.  A.  (308).  "Pain  Contrasts."  Proc.  Am.  Psych.  Assoc, 
N.  Y.,  1892-93,  1894,  25. 

Page,  M.  "De  la  douleur  epigastrique  suraigue  dans  la  neurasthe- 
nic." Cong,  de  med.  alienistes  et  neurol.  de  France,  1904,  Paris, 
1905,  ii,  567-570. 

Page,  W.  May  (397).  "Eeview  of  Nervous  System."  Brain,  1906, 
xxix,  743-803. 

Pain,  J.  S.  "Pain  as  a  Diagnostic  Factor."  Jour.  Med.  and  Surg., 
Nashville,  1903,  xciii,  243-250. 

Pal  (624,  753).  "Ueber  den  Darmschmerz."  Wiener  med.  Presse, 
1903,  No.  2,  57. 

Palier.  "Atypical  Forms  of  Pneumonia."  N.  Y.  Med.  Jour.,  Ixix, 
Ixx,  1899. 

Park,  Eoswell   (784).     "Surgery,"  583. 

Parrish,  J.  "Eefiected  or  Misplaced  Pain."  Country  Practitioner, 
Bercley,  N.  J.,  1879-80,  i,  289-295. 

Parsons,  Fingal  (308).  "Discussion  on  the  So-called  Ovarian  Pain, 
Its  Causes  and  Treatment."    British  Med.  Jour.,  1904,  1062. 

Parsons,  J.  Herbert  (200).  "Physical  Explanation  of  Muscle  and 
Nerve  Currents,"     Jour.  Phys.,  1892,  xiii,  5, 


BIBLIOGRAPHY  849 

Paetsch  (871).    Breslauer  Aertzliche  Zeitschr.,  1882,  iv,  1253. 
Pascalis,  F.     "Remarks  on  the  Theory  of  Pain."     Am,  Med.  and 

Surg.  Jour.,  Philadelphia,  1826,  i,  79-89. 
Patten.     "Theory  of  Social  Forces  and  Failure  of  Biologic  Sociol- 
ogy."    Publications  of  the  American  Academy  of  Political  and 

Social  Science,  Philadelphia. 
Peacock,  G.  (131).    "The  Diagnostic  Value  of  Pain."    Jour.  Med. 

Sci.,  Dublin,  1906,  cxxi,  1-19;  xxv,  761-766. 
Pearse,  H.  E.  (11).     "The  Interpretation  of  Recurrent  Abdominal 

Pain."     St.  Louis  Clinic,  1898,  xi,  125-129. 
Pease,  C.  A.    "Traumatic  Lumbago."    Vermont  Med.  Month.,  1909, 

XV,  213. 
Peck.    "Partielle  Empfindungslahmung."    Prager  med.  Woch.,  1888, 

xiii,  81. 
Peckham,  F.  E.    "Sciatica  and  Allied  Affections."    Tr.  Rhode  Island 

Med.  Soc.  Pr.,  1908,  vii,  646,  652. 
Percy,  J.  F.  (451).     "The  Practical  Significance  of  Certain  Com- 
mon Symptoms  in  the  Upper  Abdomen."    J.  A.  M.  A.,  July  8, 

1905,  xlv,  98. 
Pereira,  M.     "A  dor  no  ponto  de  vista  medico."     Brazil  med.,  Rio 

de  Janeiro,  1902,  xvi,  255-265. 
Perman,  E.  S.    "Ueber  die  Bedeutung  des  indirekten  Driickschmerzes 

bei   Appendicitis."     Centralblatt  fiir   Chirurgie,  Leipzig,  Dec, 

1911,  No.  49,  1593. 
Perol,   Pierre.     "La  cephalee   dans   les   tumeurs   de  I'encephale." 

These  de  Paris,  1907. 
Pershing,  H.  T.    "Treatment  of  Neuralgia."    Colorado  Med.  Jour., 

Feb.  12,  1912,  ix.  No.  2. 
Peter,  M.  (71,  763).    "Neuralgie  diaphragmatique."    Archives  gen. 

de  med.,  June  17,  1871. 
Peterson,  Frederick  (496).    "The  Seat  of  Consciousness."    J.  A. 

M.  A.,  1893,  li,  No.  22,  22. 
Peterson,    Reuben.    (625).      "A    Case    of    Thrombophlebitis    with 

Peritoneal     Neuritis     and     Paralysis     Following     Supravaginal 

Hysterectomy."      Surg.    Gyn.    and    Obstet.,    May,    1909,    517- 

521. 
Petren,  K.     "Ueber  die  Bahnen  des  Sensibilitiit  in  Riickenmark." 

Archiv  fiir  Psychiatric,  1910,  xlvii,  495. 

(286).     "Ein  Beitrag  zur  Frage  vom  Verlaufe  der  Bahnen  der 

Hautsinne  im  Riickenmarke."     Skand.   Archiv   f.   Phys.,   1902, 
xiii. 

(879).     "Klinische  Beitrage  zur  Kenntniss  der  Syringomyelie 


850  BIBLIOGRAPHY 

und  Hamatomyelie."     Deutsche  Zeitsehrift  f.  Nervenheilkunde, 
1909,  xxxvi,  401-439. 
Petren,  K.    "Eemarks  on  Sciatica  and  Morbus  Coxa  Senilis,  Espe- 
cially  with   Eegard   to   Their    Treatment."'     Eev.    Neurol,    and 
Psychiat.,  Edinburgh,  1909,  vii,  305-345,  3  pi. 

and    Bergmark    (284).       'Ueber    Sensibilitiitsstorungen    bei 

und  nach  Herpes  Zoster."  Zeitsehrift  f.  klin.  Med.,  1901, 
Ixiii,  91. 

and    Carlstrom,    G.     (285).      "Untersuchungen    iiber    die 

Art  der  bei  Organekrankungen  vorkommenden  Eeflex-Hyper- 
athesien."  Deutsche  Zeitsehrift  f.  Nervenheilkunde,  1904,  xxvii, 
464. 

Petres,  a.    "Lepre  et  syringomyelia."    Gazette  des  Hopitaux,  1892, 

65,  1287. 
Petres    and    Sabrazes.      "Lepre    systematisee    nerveuse    a    forme 

syringomyelique."     Nouvelle   Iconographie   de    la    Saltpetriere, 

1893,  211. 
Petdsen,  a.  M.   (72).     "Development  of  the  Sympathetic  Nervous 

System  in  Mammals."     Philosoph.  Trans.,  1890. 
PiCKFORD.     "Ueber  das  Verhiiltniss  der  Hyperamie  zum  Sclunerz." 

Zeitsehrift  f.  rat.  Med.,  Heidelberg,  1851,  x,  101-122. 
Piersol    (537,   703,   707,   710,   718,   724,   730,   737,   829).     "Pain 

Nerves."     "Anatomy,"   1st  ed.,  1039,   1320-52,  1683,   1870-72, 

1883,  1890,  1892,  1910. 
PilcheRj  J.  T.    "The  Cause  and  Eelief  of  Pain  in  Duodenal  Ulcer." 

Am.  Jour.  Med.  Sci.,  May,  1911;  Long  Island  Med.  Jour.,  Eock- 

ville,  N.  Y.,  Sept.,  1911;  ab.  in  J.  A.  M.  A.,  June  10,  1911,  Ivi, 

23,  1752. 
PiLCHER,  Paul   (731).     Surg.  Gyn.  and  Obst.,  February,  1910,  x, 

No.  2,  168-175. 
PiLTZ  (407).    "Ein  Beitrag  zum  Studium  der  Dissociation  der  Tem- 

peratur-  und  Schmerzenipfindung  bei  Berletzungen  und  Erkrank- 

ungen  des  Eiickenmarkes."     Archiv  f.    Psychiatric,   1906,  xli. 

Heft  III,  951. 
PiNCUS   (465).     "Experimenta  de  vi  nervi  vagi  et  sympathetic!  ad 

vasa."    Diss.  Inaug.,  Breslau,  1856. 
PiNELES.     "Kopfschmerz."     Wiener  klin.  Eundschau,  1907,  No.   2. 
PiORRY  (343).     Diet,  de  sci.  mod.,  Paris,  1813,  xxxvii,  403. 
Pitha,  von  (272).    Medical  Times  and  Gazette,  Sept.  25,  1875,  358. 
Pitt,    G.    M.    (530).      "On    Spinal    Softening,    Commonly    Called 

Myelitis,  and  on  Eecent  Advances  in  Our  Knowledge  of  the  Af- 
ferent Sensory  Tracts."    Guy's  Hosp.  Gaz.,  1909,  xxiii,  193-197. 


BIBLIOGRAPHY  851 

Pollock.     '^On  the  Importance  of  Pain  as  a  S3'niptoni  of  Disease." 

Lancet,  London,  1859,  i,  539. 
Pond,  A.  M.  (22,  174,  420).    "The  Significance  of  Epigastric  Pain.'* 

Med.  News,  N".  Y.,  Apr.  15,  1905,  Lxxxvi,  686-690. 
Porter,  J.   L.     "Painful  Feet."     Lancet-Clinic,   Cincinnati,   1908, 

xcix,  351-354. 
PoRTius,  S.     "De  dolore  liber."    Florentige,  1551. 
PosTiLLE,  J.  M.     "Periodical  Headaches."     Jour.  Okla.  Med.  Assn., 

Guthrie,  1908,  i,  14-16. 
PoTAiN  (117,  380).    "Ueber  den  Schmerz."    Internationale  klinische 

Eundschau,  Wien,  1894,  viii,  1839-1844;  Boll.  d.  clin.,  Milano, 

1895,  xii,  560-566 ;  La  medecine  moderne,  1899,  No.  64.     (Eef. 

from  Buch.) 
PoTEL,  G.  (528).     "La  douleur  en  chirurgie."     Echo  med.  du  Nord, 

Lille,  1907,  xi,  109-115. 
POTHUISJE,   P.   J.    (944).     "Pain   in  the   Epigastrium."     Colorado 

Med.  Jour.,  Denver,  1906,  xii,  219-223. 
Powells.     "Textbook  of  Physiology."     1906,  531. 
Price    (59i,   621).     "Adipositas  dolorosa."     Jour.  Am.   Med.   Sci., 

May,  1909. 
Prince,  E.  M.  (823).     "Abdominal  Pain."    Mobile  Med.  and  Surg. 

Jour.,  1906,  viii,  302-312. 
Pritchard  and  Benxece,  W.   (21,  620,  742).     "Two  Cases  of  Ob- 
scure Abdominal   Pain.     Operations.     Eesults."     British  Med. 

Jour.,  Dec.  27,  1902,  ii,  1944-1946. 
Probst,    V.    (71,    441).      "Zur    Kenntniss    der    Schleifenschicht." 

Monatsschrift  f.  Psych,  und  Neurol.,  xi. 
Propping  (857).    "Zur  Frage  der  Sensibilitat  der  Bauchhohle."  Bei- 

trag  zur  klin.  Chir.,  1909,  Ixiii,  3,  690. 
Prout  (712).    "Stomach  and  Urinary  Diseases."     1840,  354. 
Prus.     "Die  Morvan'sche  Krankheit,  ihr  Yerhaltniss  zur   SjTingo- 

myelie  und  Lepra."    Archiv  f.  Psych,  und  Nervenkr.,  1895,  xxvii, 

771. 
PuRVES,   Stewart    (255).     "Eelation  to   Cardiac   Nerves."     Prac- 
titioner, 1905,  Ixxiv,  189. 
QuiNTiN.      "Les    douleurs    postoperatoires."      Progres    med.    beige, 

Bruxelles,  1904,  vi,  165-167. 
Rabaghati,  a.  (309).     "Discussion  on  the  So-called  Ovarian  Pain, 

Its  Causes  and  Treatment."     British  Med.  Jour.,  1904,  1062. 
Eadcliffe,  C.  B.    "A  Few  Words  in  Explanation  of  the  Meaning  of 

Pain."    Med.  Times  and  Gaz.,  London,  1873,  i,  153. 
Eaiche,  F.  E.    "Quick  Control  of  Pain  and  Disease  Without  the  Use 


852  BIBLIOGRAPHY 

of  Drugs  by  the  Leucodescent  Light."  Dental  Keg.,  Cincinnati, 
1908,  Ixii,  364-368. 

Eandoll,  H.  E.  (625).  "Abdominal  Pain."  Jour.  Mich.  Med.  Soc, 
Detroit,  1904,  iii,  241-244. 

Eansohoff  (713,  723).    Keen's  "System  of  Surgery,"  iv,  188,  211. 

Eansteom  (803).  J.  A.  M.  A.,  Sept.  7,  1907,  xxxxix,  836-840. 
"Especially  pain  in  connection  with  ileus."  Quoted  by  K.  G. 
Lennander. 

Rasoei,  E.  "Sulla  cura  meccanico  del  dolore."  Bull.  d.  Soc.  Lan- 
cesiana  d.  osp.  di  Eoma,  1882,  ii,  149-151. 

Eatterman,  F.  (453,  759,  967,  1087).  "Causes  and  Locations  of 
Abdominal  Pain,  Their  Clinical  Significance,  with  Special  Eef- 
erence  to  McBurney's  Point."  Lancet  Clinic,  Cincinnati,  Oct. 
12,  1907,  xcviii,  347-350. 

Eeaney^  M.  F.  (121,  181).  "Abdominal  Pain  in  Pneumonia."  In- 
dian Med.  Gazette,  Calcutta,  May,  1907,  190. 

Eeddick,  J.  T.  (344).  "Pain."  Southern  Practitioner,  Nashville, 
1906,  xxviii,  147-150. 

Eeed,     "Gynecology."     1st  ed. 

Eeed^  a.  L.  (903).  Med.  Jour.,  New  York  and  Philadelphia,  ex, 
No.  10,  470. 

EjiED,  Chas.  L.  "Tlie  Autonomic  Manifestation  and  Peripheral  Con- 
trol of  Pain  Originating  in  the  Uterus  and  Adnexa."  J.  A. 
M.  A.,  Mar.  25,  1911,  Ivi,  12,  861. 

Eeed,  W.  C.  "Some  Aspects  of  Abdominal  Pain  in  Woman."  Jour. 
Surg.  Gyn.  and  Obst.,  1908,  xxx,  28-47. 

Eegis,  Berth.  "Sciatique  radiculaire,  type  Jacob-Sabareanu."  These 
de  Paris,  1905. 

Eeinbold.  "Ueber  die  Bedeutung  des  Schmerzes  in  pathologischer 
und  therapeutischer  Beziehung."  Chir.  und  Augenheil.,  Berlin, 
1842,  ii,  1-26. 

Eenauldin.    "Douleur."    Diet,  de  sci.  med.,  Paris,  1814,  x,  178-239. 

Eethi.     "Nasaler  Kopfschmerz."    Med.  Klin.,  1908,  No.  16. 

Eeyniee,  Paul  (231).  "Semeiological  Value  of  a  Painful  Point  in 
the  Left  Hypochondrium.  Symptomatic  of  Gas  in  Large  Intes- 
tine." Jour,  de  med.  de  Paris,  Apr.  1,  1900.  Ab.  in  Med.  Eec- 
ord,  Apr.  21,  1900,  969. 

Eeynolds,  Edward,  and  Lovett,  Egbert  W.  (805).  "An  Experi- 
mental Study  of  Certain  Phases  of  Chronic  Backache."  J.  A. 
M.  A.,  Mar.  26,  1910,  liv,  No.  13,  1033. 

RiBOT,  T.  (71).  "Pathological  Pleasures  and  Pains."  Monist,  Chi- 
cago, 1895-96,  vi,  176-187. 


BIBLIOGRAPHY  853 

EiCHAEDSON,  F.  C.  (197).    "Abdominal  Pain."    New  England  Med. 

Gaz.,  Boston,  1907,  xlii,  20-24. 
EiCHARDSON,  Maurice   (243,  491).     "Papers  on  the  Diagnosis  of 

Appendicitis."     Boston  Med.   and  Surg.  Jour.,  Apr.   10,   1902, 

cxlvi,  No.  16,  399. 

(114,241).  "Eemarks  on  the  Diagnosis  Between  Acute  Appen- 
dicitis and  Acute  Intrathoracic  Disease."  Boston  Med.  and  Surg. 
Jour.,  Apr.  17,  1902,  cxlvi,  No.  16,  29. 

. (18,  23,  242,  756,  826,  912).     "The  Significance,  Pathological 

and  Clinical,  of  Abdominal  Pain."    Boston  Med.  and  Surg.  Jour,, 

1902,  cxlvi,  No.  8,  187,  189-190,  219. 
EiCHERAND,  A.  (70).    "Elements  of  Physiology."    2d  ed.,  1829,  613. 
EiCHET^  C.    (236).     "Etude  biologique  sur  la  douleur."     Eev.  sci., 

Paris,  1896,  vi,  4,  225-232. 

.     "Eecherches  sur  la  sensibilite,"  284. 

EiEDEL.    "Der  Kopfschmerz  und  seine  Behandlung."    Berliner  klin, 

Woch.,  1907,  No.  20. 
EiEDEL,  B.   (865).     "Zur  Frage  der  Narkose  bei  der  Ovariotomie." 

Centrb.  fiir  Chir.,  1882,  No.  9. 
EiNTON,  J.  C.    "Sciatica  and  Its  Surgical  Treatment."     Proc.  Eoy. 

Soc.  Med.  Surg.,  London,  Dec.  16,  1907-08,  167-175. 
EiPOLi.     "Considerations  sur  la  douleur  dans  les  maladies,  et  par- 

ticulierement   dans   I'inflammation."      Eev.    med.    de    Toulouse, 

1872,  vi,  97-112. 
EiTTER,  C.    "Zur  Frage  der  Sensibilitat  der  Bauchorgane."    Central- 

blatt  f.  Chirurgie,  Leipzig,  1908,  xxxv,  609-615. 
EiVERS  and  Head  (86).    "A  Human  Experiment  in  Nerve  Division." 

Brain,  Nov.,  1908,  ii,  323-450. 
EoBBiNS,  H.  A.    "Syphilis  of  the  Brain  and  Spinal  Cord."    Am.  Jour. 

Dermat;  and  Genitourinary  Diseases,  St.  Louis,  1908,  xii,  244- 

249. 
Egberts  (127).    "Eeferred  Pain  in  Paranephritis."    Am.  Jour.  Med. 

Sci.,  Apr.,  1883,  390-408. 
Egberts,  J.  B.  (576,  846).     "Congestion  of  the  Lower  Lobe  of  the 

Eight    Lung    an    Early    Symptom    in    Appendicitis."      Annals 

of  Surg.,  1910,  No.  6,  846. 
Eobinson,  B.  (3,  25,  833).     "Sudden  Abdominal  Pain,  Its  Signifi- 
cance."    Med.  Fortnightly,  1906,  xxix,  351-358,  531;  xxx,  377. 

(24,  337).    "Sudden  Acute  Abdominal  Pain,  Its  Significance." 

Univ.  Med.  Mag.,  Philadelphia,  1896',  viii,  912-922. 

Eobinson,  Henry  (67,  265,  841,  842,  843).  "The  Clinical  Bearing 
of  Cutaneous  Tenderness  of  Various  Acute  Abdominal  Disorders. 


854  BIBLIOGRAPHY 

Especially  Appendicitis."     Quarterly  Joiir.  Med.,  July,  1908,  i, 
Xo.  4,  387-416. 
EoBSOX,  Mayo  (83).    "Gall  Bladder."    British  Med.  Jour.,  1897,  1, 
643. 

(618).     "Perforative   Peritonitis."     Keen's   "System   of    Sur- 
gery," iii,  856. 

EoBSOX  and  Cammidge  (822,  827).    "The  Pancreas,  Its  Surgery  and 

Pathology,"  35,  399. 
EocH  and  De  Sexarcleus  (477).    Semaine  med.,  "De  I'ileus  neuro- 

pathique  avec  vomissements  de  matieres  fecales."    May  19,  1909, 

xxix,  Xo.  20,  229-236. 
EocHARD,  J.  (452).    "La  douleur;  question  d'hygiene  sociale."  Paris, 

1891,  231-283. 
EocHET  (365).    "Cystalgies  des  femmes."    Annales  d.  maladies  d'or- 

ganes  gen.  urinaires,  Paris,  1907.  1041-1120. 
EOETROCK,  J.  L.   (139).     St.  Paul  Med.  Jour.,  1906,  viii,  456. 
EoGERS,  M.  H.  "Abdominal  Pain  from  Anterior  and  Posterior  Curva- 
ture."    Boston  Med.  and   Surg.  Jour.,  Aug.  3,  1911.     Ah.  in 

J.  A.  M.  A.,  Aug.  26,  1911,  Ivii,  9,  769. 
EoLLESTON  (806,  813).  "Diseases  of  the  Liver,  Gall  Bladder  and  Gall 

Ducts,"  512,  725. 

(619).     "Peritonitis."     Osier's  "System  of  Medicine,"  v,  572. 

EoMSTROM    (363).      "Untersuchungen   iiber   die    Nerven    des    Dia- 

phragmas."     Anatomische  Heft,  1906,  xxx,  92  (Fr.  Merkel  and 

E.  Bonnet). 
EoosiNG,  F.    (61,  835).     "Indirect  Production  of  Typical  Pain  at 

McBurney's  Point  by  Indirect  ]\[eans."     Centralblatt  f.  Chirur- 

gie,  Leipsig,  Oct.  26,  1907,  Xo.  43,  1257-1280.    Ab.  in  J.  A.  M. 

A.,  Nov.  30,  1907,  1882. 
EosE,  M.    "On  Disturbed  Sensation  in  Certain  Diseases  of  the  Cord." 

Przegl.  lek.  Krakau,  1908,  xlvii,  500-503. 
EoSENBACH.     "Ueber   die   neuropathischen   Symptome   der  Lepra." 

Neurologisches  Centralblatt,  1884,  iii,  361. 
EosiN,  H.    (936).     "Einiges  iiber  das  epigastrische  Druckgefiihl." 

Med.  Woche,  Halle  a/d  Saale,  1907,  viii,  337. 
EosNER,  A.   (922).     "Intermenstrual  Pains."     Przegl.  lek.  Krakau, 

1905,  xliv,  435,  462. 

Boss,  Geo.  (322).    "On  the  Eelief  of  Certain  Headaches  by  the  Ad- 
ministration of  One  of  the  Salts  of  Calcium."    Lancet,  Jan.  20, 

1906,  143-146. 

Eoss,  J.   (68,  129,  135,  161).     "On  the  Segmental  Distribution  of 
Sensory  Disorders."     Brain,  1888,  x,  333,  344. 


BIBLIOGRAPHY  855 

EossBACH  (623).  "Scleroses  of  Abdominal  Vessels."  Miinchener 
med.  Woch.,  May  11,  1909,  Ivi,  No.  19,  974-975. 

EosTHOEN"   (850).     "x4.ntrittsvorlesung."     Wiener  klin.  Woch.,  1908. 

EoTHMAN^  M.  (442).  "Zur  Anatomie  und  Physiologie  des  Vorder- 
strangs."     Xeurologisches  Centralblatt,  1903,  704. 

(438)'.     "Ueber  die  combinierte  Ausschaltung  eentripetaler  Lei- 

tungsbahnen  im  Eiickenmarke."     Physiol.   Gesellschaft,  Berlin, 
1904-05,  Xo.  13. 

(280).     "Ueber  die  Leitung  der  Sensibilitat  ira  Elickenmarke." 

Berliner  klinische  Woch.,  Sept.,  1906,  Nos.  2  and  3. 

EoTHKOCK,  J.  L.  (169,  892).  "The  Significance  of  Pain  in 
Gynecologic  Diagnosis.''  St.  Paul  Med.  Jour.,  1906,  viii,  456, 
467. 

Eoux,  J.  (338).  "Lesions  of  the  Sympathetic  System  in  Tabes.*' 
Paris. 

(450).      "La    sensation    douloureuse    etude    psychologique." 

Provence  med.,  Lyons,  1896,  x,  485-492. 

.    "Da  la  douleur  consideree  au  point  de  vue  chirurgicale."    Gaz. 

des  hop.,  Paris,  1847,  ix,  2,  563. 

(858).     "Maladies  du  tube  digestif."     Paris,  1907.     Cited  by 

Neuman,  Slesinger,  etc. 

EovsiNG^  T.  (190).    "Indirectes  Hervorrufen  des  typischen  Schmerzes 

an  McBurney's  Punkt."    Centralblatt  f.  Chirurgie,  Oct.  26,  1907, 

xxxiv,  No.  43.    Ab.  in  J.  A.  M.  A.,  1907,  xlix,  1883. 
EuNNELS,  0.  S.  (966).    "Abdominal  Pain."    N.  Am.  Jour.  Homeop., 

N.  Y.,  1905,  liii,  590-598. 
EussEL,  J.  M.  (378).    "Paroxysmal  Abdominal  Pain  Associated  with 

Symptoms  of  Epilepsy."     Birmingham  Med.  Eev.,  1905,  Iviii, 

695-702. 
EussEL,  E.  (416,  428).    Brain,  1908,  xxi.  No.  82,  160-164. 
EussEL  and  Horsley.    "Note  on  the  Apparent  Eepresentation  in  the 

Cerebral  Cortex  of  the  Type  of  Sensory  Eepresentation  as  It 

Exists  in  the  Spinal  Cord."     Brain,  1906,  xxix,  137. 
Eyder^  G.  (35).     "Surgical  Pain."     Boston  Med.  and  Surg.  Jour., 

Aug.  18,  1900,  cxliii,  149-155. 
Sabino^  Coelho.     "0  tratamento  do  cancero  do  utero."     Jour.  soc. 

d.  sci.  med.  de  Lisboa,  1903,  Ixvii,  3-7. 
Sabli.     "Lehrbuch   der  klinischen   TJntersuchungsmethoden,"    1902, 

702. 
Sabourin,  C.    "Local  Tenderness  on  Pressure  in  Tuberculosis."  Med. 

Press  and  Circmlar,  London,  Nov.  9,  1910. 
Sabiiazes  and  Dutekix   (573).     Arch.  d.  mal.  d.  coeur    d.  vaisseaux 


856  BIBLIOGRAPHY 

et  d.  sang,  1909,  cclvii.  Ab.  in  J.  A.  M.  A.,  cxxxviii,  No.  2, 
284. 

Sachs  (594,  622).  "Eeport  of  Cases  of  Eeynaiid's  Disease."  Am. 
Jour.  Med.  Sci.,  Oct.,  1908. 

Sacpis,  E.  "On  the  Structural  and  Functional  Changes  of  the  Optic 
Thalamus."     Brain,  1909,  xxxii,  95. 

Saenger  (362,  920).  "Die  Tripperansteckung  beim  weiblichen  Ge- 
schlecht."     1890. 

Sahli  (485).    "Diagnosis,"  71. 

(463).     "Lehrbuch    der    klinischeu    Untersuchungsmethoden." 

3te  Auflage,  726. 

Sajous,  Charles  E.  (620).  "Adrenal  Hemorrhage."  Monthly  Cy- 
clopedia, ii,  No.  10,  597. 

Sampson^  J.  A.  (50,  118,  915).  "Eelation  of  Ovarian  Cysts  to  Ab- 
dominal and  Pelvic  Pain."  Surg.  Gyn.  and  Obst.,  June,  1907, 
iv,  685. 

Sans,  Fernandez.  "Un  casu  de  compression  del  plexo  braquial  por 
neoplasia,  con  autopsia."    Siglo  med.,  Madrid,  1909,  Ivi,  274-276. 

Saundly,  Egbert  (290).  "Headaches  of  Eenal  Origin."  Prac- 
titioner, 1906,  19-21. 

Savtll,  J.  D,  "Cases  Illustrating  Symptoms  Eeferable  to  the 
Ends  of  the  Extremities."  Hospital,  London,  1908-09,  xlv, 
137. 

Sawyer,  Sir  James  (80).  "Note  on  the  Cause  and  Cure  of  a  Form 
of  Backache."    Lancet,  1887,  i,  17. 

Scarenzio,  a,  "Sulla  sede  della  addolorabilita."  Annal.  med.,  Mi- 
lano,  1857,  clx,  272. 

ScHAPPS^  J.  C.  "Concerning  Pain  in  the  Lower  Part  of  the  Back, 
the  Hips,  and  Extending  Down  the  Thigh."  Northwest  Medi- 
cine, July,  1910,  ii,  7,  209-210. 

Schepelman,  E.  "Differential  Diagnosis  Between  Pleurisy  Without 
Effusion  and  Intercostal  Neuralgia."  Berliner  klin.  Woch.,  June 
12,  1911,  xlviii.  No.  24,  1078. 

ScHiEF.  "Ueber  die  Erregbarkeit  des  Eiickenmarks."  "Physiologic," 
i,  251  ff.     Pfliiger's  Archiv,  xxviii,  537. 

Schilling,  F.  (907).  "Die  Druckempfindlichkeit  und  die  Druck- 
punkte  des  Abdomens."  Centralblatt  f.  innere  Medizin,  Leipzig, 
1907,  xxviii,  777-782. 

ScHiviN,  J.  "The  Diagnostic  Significance  of  Abdominal  Pain."  West 
Virginia  Med.  Jour.,  Wlieeling,  1907-08,  ii,  231-235. 

ScHLEiCH,  C.  L.  "Ueber  den  Schmerz."  "Therapie  der  Gegenwart," 
Berlin,  March,  1902,  iv,  97-106. 


BIBLIOGRAPHY  857 

ScHLESiNGEB,  H.     "Ein  Beitrag  zur  Kenntniss  des  Hungerfiihles." 

Wiener  klin.  Woch.,  1893,  vi,  Heft  31,  566-568. 
.     "Beitrage     zu     den     Sensibilitatsabnormalien     bei     Lepra/' 

Deutsche  Zeitschrift  f.  Nervenheilkunde,  1892,  ii,  230. 
.     "Die  Lokalisation  der  Schmerz-  und  Temperatursinnesbahnen 

im    Eiickenmarke."      Xeurologisches     Centralblatt,    1895,    xiv. 

(Ref.) 
.     "Die  Syringomyelie."    Leipzig  and  Wien,  1895. 


Schmidt,  E.  (564-584,  709,  785,  779,  801,  804,  819,  823).  "Die 
Schmerzphenomene  bei  inneren  Krankheiten;  ihre  Pathogenese 
und  Ditferentialdiagnose."  Wien  and  Leipzig,  1906,  "Diagnos- 
tic Significance  of  Pain."  Amer.  trans.,  1908,  101  (Lippincott), 
23,  72,  101-132,  212-213,  215-217,  229-230,  245,  253; 

ScHMiTTEE,  F.     "Metatarsalgia."    J.  A.  M.  A.,  1908,  1,  688. 

ScHMUCKER^  A.  "Ueber  die  Auslosung  von  Schmerzempfindungen 
durch  Summation  sich  zeitlich  folgender  sensibler  Eeize  bei  Com- 
pressionsmyelitis.  Ein  Beitrag  zur  Physiologic  des  Schmerzes.'* 
Wiirzburg,  1892. 

ScHNTDER.  "Der  Kopfschmerz  der  Xeuropathen."  Xeurologisches 
Centralblatt,  1910,  Xo.  13. 

ScHOEMAKER,  J.  Y.  "Paresthesia."  Med.  Bull,,  Philadelphia,  1908, 
XXX,  121. 

.      "Metatarsalgia,   Anterior."      Xederl.    Tijdschr.    v.    Geneesk. 

Anist,  1909,  i,  1859-1861. 

.     "Syphilitic  Myelitis.     A  Clinical  Lecture."     Cleveland  Med. 

Jour.,  1908,  vii,  91-94. 

SoHOEN,  "Kopfschmerzen."  Wiener  klin.  Eundschau,  1901,  Nos.  35 
and  36. 

ScHOLL,  E.  (186).  "Blutungsschmerzen  und  Altersbild  der  gyna- 
kologischen  Erkrankungen."  "Gynakologie,"  Leipzig,  1907,  xii. 
No.  1  (Hagars). 

Schubert.  "Die  Blutentziehung  als  schmerzstillendes  Mittel."  Yer- 
offentl.  d.  Hufeland  Gesellschaft  in  Berlin,  Balneologische  Gesell- 
schaft,  1899,  xx,  252-256;  Deutsche  med.  Zeitung,  Berlin,  1899, 
XX,  645. 

ScHULHOF^  W.  "Zum  heutigen  Stand  der  Diagnose  und  der  Thera- 
pie  der  Ischias."  Pester  mediz.  Presse,  Budapest,  1908,  xliv, 
445,  475. 

ScHULTZ  (430).     Archiv  f.  Psychiatrie,  1880,  x,  179. 

ScHUPFER,  F.  (761).  "Sui  dolori  di  origine  centrale."  Eiv.  sper.  di 
freniat,  Eeggio,  1898,  xxiv,  582-604   (Emilia). 

Schwartz,  W.  H.    "De  dolore  lienis,  affectu  hypochondriaco  et  scor- 


858  BIBLIOGRAPHY 

buto."  Eolfinck  (W.),  "Epithome  meth.  cognose  (Ect.)/'  Jena, 
1655,  237,  256. 

Scott,  E.  L.    Southern  Med.  Jour.,  Nashville,  1908,  i,  6,  12. 

Scott,  F.  H.  (19,  253).  "On  the  Metabolism  and  Action  of  Nerve 
Cells."    Brain,  xxviii,  506-524. 

Sedillot,  C.  "De  la  suppression  de  la  douleur  apres  les  operations." 
Gaz.  hebdom.  de  med.,  Paris,  1870,  2  s.,  vii,  346,  361. 

Seidle,  F.  "Die  diagnostische  Bedeutung  der  dorsalen  Schmerz- 
punkte  des  runden  Morgengeschwiires."  Archiv  fiir  Verdauungs- 
krankheiten,  Berlin,  Dec.,  1911,  xvii.  No.  6;  ab.  in  J.  A.  M.  A., 
Jan.  27,  1912,  Iviii,  No.  4,  313. 

Seifer  (412).  "Das  spinale  Sensibilitatsschema  zur  Segment-Diag- 
nose der  Eiickenmarkskrankheiten."  Archiv  f.  Psychiatric,  1901, 
xxxiv.  Heft  2,  648. 

Selby  (754).  "The  Diagnosis  of  Perforation  of  the  Bowel  in  Ty- 
phoid."   J.  A.  M.  A.,  xlviii,  25,  2108. 

Semeleder,  F.  (64).  "El  dolor."  Gaz.  med.,  Mexico,  1892,  xxviii, 
300-353. 

Senator.  "Die  Erkrankungen  der  Nieren,"  in  H.  Nothnagel's 
"Specieller  Pathologic  und  Therapie."     Wien  (Holder). 

Shackey^  Seymour  J.  (456).  "Hysteria  and  Neurasthenia."  Brain, 
1904,  xxvii,  1-26. 

Shallon,  W.  M.  "Pain,  with  Special  Eeference  to  Its  Dental  Eela- 
tions."    Brooklyn  Med.  Jour.,  1888,  ii,  97-112. 

Sherren,  James  (267).  "The  Causation  and  Treatment  of  Appen- 
dicitis."   Practitioner,  London,  1905. 

(396).     "A  Case  of  Secondary  Suture  of  Great  Sciatic  Nerve." 

British  Med.  Jour.,  Feb.  16,  1907. 

(612).     "The  Diagnosis  of  Injuries  of  the  Peripheral  Nerves 

from  Those  of  the  Spinal  Cord."  Internat.  Clin.,  Philadelphia, 
1908,  18,  iii,  247-258. 

.'    "Injuries  of  Nerves  and  Their  Treatment."    Lancet,  Mar.  31, 

1906. 

(92,  146,  237,  266).     "On  the  Occurrence  and  Significance  of 

Cutaneous  Hyperalgesia  in  Appendicitis."  Lancet,  Sept.  19, 
1903,  ii,  816-821. 

(789).    "Some  Surgical  Observations  on  Eef erred  and  Eeflected 

Pain."    Clin.  Jour.,  Loudon,  1905,  xxvi,  168-173. 

Sherrington^  C.  S.  (205,  540).  "On  the  Anatomical  Constitution 
of  Skeletal  Muscles,  with  Eemarks  on  Eecurrent  Fibers  in 
the  Ventral  Spinal  Nerves."  Jour.  Phys.,  1894-95,  xvii,  211- 
g58. 


BIBLIOGRAPHY  859 

Sherrington.  C.  S.  '^'Distribution' of  the  Deep  AflPerents,  Tlieir 
Function  and  Distribution."  British  Med.  Jour.,  London,  1909, 
ii,  679-680. 

(247,  248,  399).  "Experiments  in  Examination  of  the  Periph- 
eral Distribution  of  the  Fibers  of  the  Posterior  Eoots  of  Some 
Spinal  Xerves."  Part  I,  Phil.  Trans.  Eoy.  Soc.,  1893,  clxxxiv, 
B,  6-11;  part  II,  Phil.  Trans.  Eoy.  Soc.,  1898,  clxxxx,  B,  45. 

(499,  522).     "The  Integrative  Action  of  the  Xervous  System.". 

"Physiology,"  New  York,  1906,  1909. 

(281).     "The  Spinal  Eoots  and  Dissociative  Anesthesia  in  the 

Monkey."    Jour.  Phys.,  Loudon.  1901-02,  xxvii,  360. 

Shore,  L.  E.  (201).     "A  Contribution  to  Our  Knowledge  of  Taste 

Sensation."    Jour.  Phys.,  1892,  xiii,  191. 
Shunberg,   Tn.    (283).     "Enny   algesimeter."      (Ein  neuer   Alge- 

simeter  nebst  einer  kritischen  Darstellung  der  bisherigen  alge- 

simetrischen  Methoden.)     L^psala  Lakaref.  Fock.,  1902-03,  viii, 

560-566;  Deutsche  Zeitschrift  f.  Xervenheilkunde,  1904,  xxviii, 

559. 
SiCARD,    J.    A.      "Diagnostic    des    neuralgies    faciales,    neuralgisme 

facial."     Presse  med.,  Paris,  1909,  xvii,  283-298. 
Sieveking,  E.  H.     "On  the  Etiology  of  Pain."     British  Med.  Jour., 

1867,  i,  131-135. 
Signorelli  (425).     "Epitome  on  Pain."     British  Med.  Jour.,  June 

4,  1904,  89. 
Singer.     Psychological  Eev.,  May,  1897,  iv,  3,  250. 
SiNiON,  E.  M.     "The  Nerve  Sheath  in  the  Causation  and  Treatment 

of  Neuralgia."     British  Med.  Jour.,  London,  1909,  i,  890. 
SiPPY,  B.  W.    "Lesions  of  the  Conus  Medullaris  and  Cauda  Equina." 

J.  A.  M.  A.,  1902,  xxxviii,  No.  19,  1195. 
Smitpi,  E.  0.   (944).     "Abdominal  Pain,  Its  Surgical  Importance." 

Lancet-Clinic,  Cincinnati,  1906,  Ivii,  113-120. 
Smith,  F.  J.     "A  Clinical  Lecture  on  Pain  in  the  Chest."     Clin. 

Jour.,  London,  1904,  xxiv,  257-262. 
Smith,  Hetwood  (305,  306).    "Discussion  on  the  So-called  Ovarian 

Pain,  Its  Causes  and  Treatment."     British  Med.  Jour.,   1904. 

1060-1061. 
Smurthwaite.     "Headache;  Pathological  Conditions  of  the  Middle 

Turbinal  a  Causal  Factor."    British  Med.  Jour.,  1906,  No.  2394, 

1368. 
Sneguereff,  "W.  F.  "Ueber  die  Schmerzen  in  der  Becken-  und  Bauch- 

hohle  der  Frau."    Archiv  f.  Gyn.,  Berlin,  1900,  Ixii,  1-33. 
' (923).     "Significance   of   Pains   in   Female   Pelvic   and   Peri- 


860  BIBLIOGRAPHY 

toneal  Cavities."  Klinitschesky  Jour.,  Moscow,  1900,  ii,  1.  Ab. 
in  J.  A.  M.  A.,  May  19,  1900,  1257. 

iSxEGUiREFF,  Y.  V.  (456).  "Isstiedovanije  useovity  klassifikasii  bole- 
vikh  oshtshushtshenij"  ("Investigation  of  the  Conditions  of  the 
Classification  of  Painful  Sensation"),  Urach  Gaz.,  St.  Peters- 
burg, 1906,  xiii,  93,  119-155. 

Snow^  Herbert  (302).  "Discussion  on  the  So-called  Ovarian  Pain, 
Its  Causes  and  Treatment."  British  Med.  Journal,  1904, 
1060. 

Solder,  v.  (435).  "Degenerierte  Bahnen  im  Harnstrange."  Neuro- 
logisches  Centralblatt,  1907,  309. 

SoMME,  C.  L.    "Dissertation  sur  la  douleur."    Strasbourg,  1806. 

SoxNENBERG  (371).  "Bcitrage  zur  Differentialdiagnose  der  Entziind- 
ungen  und  Tumoren  der  Theoeoccalgegend."  Berliner  klin. 
Woch.,  1897,  xxiv,  810. 

SouPAULT  (1136).  "Les  douleurs  gastriques."  Jour,  de  sci.  med.  de 
Lille,  1904,  ii,  385-400. 

Spearman,  C.  (410).  "Analysis  of  Localization  Illustrated  by  a 
Brown-Sequard  Case."  British  Jour.  Psych.,  1905,  i,  part  III, 
286. 

Spelissy  (372).  "Abscesses  in  the  Eight  Iliac  Eegion  and  Other 
Lesions  Not  of  Synacologic  or  Appendiceal  Origin  Mistaken  for 
Appendicitis."     x\nnals  of  Surg.,  June,  1902,  766. 

Spiller,  W.  G.  "A  Case  of  Circumscribed  Serous  Spinal  Menin- 
gitis, a  Little  Recognized  Condition  Amenable  to  Surgical  Treat- 
ment."    Am.  Jour.  Med.  Sci.,  1909,  cxxxvii,  Nos.  95-97. 

(445).  "Occasional  Resemblance  Between  Caries  of  the  Ver- 
tebra and  Lumbar  Syringomyelia."     Univ.  of  Penn.,  1905. 

("iSl).  "Sensory  Segmental  Area  of  the  Umbilicus."  Phila- 
delphia Med.  Jour.,  Feb.  8,  1902,  293. 

Spiller,  W.  J.,  and  Camp,  C.  D.  "Sensory  Tract  in  Relation  to 
Inner  Capsule."  Jour,  of  Nerv.  and  Ment.  Dis.,  Feb.,  1912, 
xxxix,  No.  2. 

Splitzner  (787).  "Modern  Medicine,"  vii,  753.  Quoted  by  Smith. 
Ely  Jelliffe. 

Stantox,  W.  D.  (832).  "Some  Practical  Points  Associated  with 
Appendicitis."  British  Med.  Jour.,  Feb.  6,  1904.  Ab.  in  Am. 
Med.  Jour.,  Mar.   26,  1904. 

Starr,  Allen  (402).  "Local  Anesthesia  as  a  Guide  in  the  Diag- 
nosis of  Lesions  of  the  Lower  Spinal  Cord."  Am.  Jour.  Med. 
Sci.,  July,  1892,  iv,  15. 

(403).     "Local   Anesthesia  as   a    Guide   to   the   Diagnosis   of 


BIBLIOGRAPHY  861 

Lesions  of  the  Upper  Part  of  the  Spinal  Cord."     Brain,  189-i, 

xvii,  481. 
Staek,  M.  a.     "A  Case  of  jSTeuralgia  Limited  to  the  Sensory  Fila- 
ment of  the  Seventh  iSTerve."     Jour.  Nerv.  and  Ment.  Diseases, 

Lancaster,  1908,  xxxv,  583. 

■ .     "Familiar  Forms  of  Xervous  Diseases,"  173-175, 

■ (42,    216).      "Subconscious    Pain,    Successful    Treatment    by 

Hypnotism."    Internat.  Clinics,  Philadelphia,  1892,  iv,  230-238. 
Steedlt,  B.  B.    "Pain  as  a  Symptom  of  Disease  Involving  the  Eight 

Half  of  the  Abdomen."    Jour,  of  the  Southern  Cal.  Med.  Assoc, 

Xov.,  1910. 
Steixer,  Walter  E.  (617).    "Myositis."    Osier's  "System  of  Medi- 
cine," 1st  ed.,  vi,  584. 
Steinhardt,  J.   D.     "Painful   Heels."     N.   Y.   Med.   Jour.,   1909, 

Ixxxix,  626. 
Steixhauser    (339).      "Experimenta    Nounulla    de    Sensibilita    et 

functione  intestini  crassi."    Leipzig,  1831,  19. 
Steetz^  G.  (282).    "Ueber  eine  isolierte  einseitige  Yerletzung  der  12. 

Dorsal  bis  4.  Lumbarwurzel  infolge  einer  atypischen  Wirbelfrak- 

tur."     Mitteilungen  a.  d.  Hamburgischen  Staatskrankenanstalt, 

Jahrbuch  derselben,  ix,  Sept.  2. 
Stewart,  T.  G.    "Gummatous  Meningitis  Involving  the  Spinal  Eoots 

on  the  Eight  Side  of  the  Cord  from  the  Tenth  Dorsal  to  the  First 

Sacral,  Inclusive."     Proc.  Eoy.  Soc.  Med.,  London,  1908-09,  ii, 

Neurol.  Sect.,  38-40. 
Stekto,  Mlle.  J.,  and  Stefanowska,  Mlle.  M.     "Eecherches  alge- 

simetriques."     Acad.  roy.  de  Beige  bull,  de  la  cl.  de  sci.,  Brux- 

elles,  1903,  199-282. 
Stockton^  C.  G.   (26,  675).     "Abdominal  Pain  from  Unsuspected 

Irritation  of  the  Internal  Hernial  Eing."    Am.  j\Ied.  Sci.,  Phila- 
delphia, 1904,  vii,  1017. 
Stodolny,  a.    "De  doloribus  posthumis."    Vienna,  1774. 
Stranskt,  E.     "Zur  Pathologic  des  Schmerzsinnes."     Monatsschrift 

f.  Psychiatric  u.  Xeurologie,  Berlin,  1902,  xii,  531-535. 
Strehlen.     "~\^on  der  Beschreibung  des  Schmerzes."     Med.  Corr.- 

Blatt.  bayr.  Aerzte,  Erlangen,  1841,  ii,  817-824. 
Strong,  C.  D.   (71,  470,  533).     "Physical  Pain  and  Pain  Xerves." 

Psychological  Eeview,  N.  Y.  and  London,  1896,  iii,  64-68. 
(249,    473).     "The    Psychology   of   Pain."      Psychol.    Eeview, 

X.  Y.  and  London,  1895-96,  ii,  329-377. 
Strubixg.     "Krankheiten  der  Nase  und  ihrer  Nebenhohlen  u.  s.  w." 

Ebstein-Schwalbe's  "Handbuch  der  praktischen  Medizin,"  1905. 


862  BIBLIOGRAPHY 

Steumpell  (211).  "Ueber  die  Bedeutimg  der  Sensibilitatspriifungen 
mit  besondercr  Beriicksichtigung  des  Drucksinnes."  Deutsche 
med.  Woch.,  Sept.  22,  1901,  Jahrgang,  xxx,  Ko.  39,  1411;  No. 
40,  1460. 

SuDDUTH^  W.  Xavier  (462,  472).  "A  Study  in  the  Psychophysics 
of  Pain."     Chicago  Med.  Eecorder,  1897,  xiii,  329-337. 

SwARTs,  Vesta  M.  (471).  "Cerebral  Centers  for  Pain."  Tr.  In- 
diana Med.  Soc,  Indianapolis,  1898,  24-29. 

Swift,  E.  J.  "Sensibility  to  Pain."  Am.  Jour.  PhysioL,  1899-1900, 
xi,  312-317. 

Stndacker.  "Oculare  Kopfschmerzen."  Klinische  Monatsblatten 
fiir  Augenheilkunde,  1909. 

Taylor,  James  (291,  632).  "Intracranial  Disease  as  a  Cause  of 
Headache."    Practitioner,  1906,  21-25. 

Tecklenburg  (467).  "Ueber  den  Einfluss  des  Nervensystems  auf 
die  Eesorption."    Diss.,  Jena,  1894. 

Theilhaber  (344).  "Die  sogenannte  chrouische  Metritis:  ihre  Ur- 
sachen  und  ihre  Symptome."     Archiv.  f.  Gynakologie,  Ixx,  424. 

(346).     "Die   Ursache   und   Behandlung  der   Menstrualkolik." 

Miinchener  med.  \Yoch.,  1901,  Xos.  22-23. 

Thibierge.    "Lepre  anesthetique  et  syringomyelic."   Gazette  hebdom- 

adaire,  1891. 
Thomas,  C.   P.     "Abdominal  Pain."     St.  Louis   Med.   Eev.,  Feb., 

1911;  Colo.  State  Jour.  Med.,  Aug.,  1911. 
.     "The    Significance    of    Pain,    Especially   in    the    Abdominal 

Cavity."    St.  Paul  Med.  Jour.,  Minn.,  1903,  v,  422-425. 
Thomas,  H.  M.,  and  Gushing^  Harvey  (512),     "Location  of  the 

Sensory  Areas."    J.  A.  M.  A.,  Mar.,  1908,  No.  14,  1,  847-856. 
Thomas,  J.  J.  (589).    "Five  Cases  of  Injury  of  the  Cord  Resulting 

from  Fracture  of  the  Spine."     Med.  and  Sursr.  Reports  of  the 

Boston  City  Hospital,  series  XI,  1900,  1. 
Thomas,  J.  L.  (27).    "The  Causes  of  Acute  Abdominal  Pain  in  the 

Healthy,  Exclusive  of  Traumatism."     British  Med.  Jour.,  1903, 

ii,  186-188. 
Thompson,    Sir   Henry    (269).     "Urethral    Stricture."     London, 

1869,  95. 
Thompson,  H.  Campbell  (43).     "On  the  Use  of  Alkalies  for  the 

Relief  of  Pain."    British  Med.  Jour.,  1903,  i,  195. 

(630).  "Causation  and  Treatment  of  Headaches."  Prac- 
titioner, 1906,  15-19. 

Thompson,  Theodore  (204).  "Familial  Atrophy  of  Hand  Muscles." 
Brain,  1908,  xxxi,  287. 


BIBLIOGKAPHY  863 

Thompson,  W.  H.  (3G,  488,  561,  596,  714,  730).  "The  Significance 
of  Pain."  Med.  News,  N.  Y.,  Dec.  19,  1896,  Ixix,  695-699;  Med. 
News,  N.  Y.,  1897,  Ixx,  No.  2,  321-326. 

Thorburn  (404).  "A  Contribution  to  the  Surgery  of  the  Spinal 
Cord."    London,  1889. 

(73,    405).    "The    Sensory    Distribution    of    Spinal    Nerves." 

Brain,  1893,  xvi,  355. 

Thorburn  and  Williamson.      "Encyclopedia    medica,"   1901,  viii, 

282. 
Thunberg    (212).      "Physiologic    des    Druckes,    Temperatur    und 

Schmerzempfindungen."     Nagel's   "Handbuch    d.    Physiologic," 

iii,  647. 
TiBBETS,   T.   M.     "Esophagismus."     Practitioner,   London,   August, 

1911,  236.    Ab.  in  J.  A.  M.  A.,  Sept.  2,  1911,  Ivii,  10,  851. 
TiGERSTEDT  (483).     'Thysiolog5%"  466-467. 
TiLLMANS.    "Shon's  Overlapping  of  Areas  of  Cutaneous  Sensibility." 

Archiv  f.  klinische  Chirurgie,  1882,  xxvii,  1-103. 
TissiE,  P.    (397).     "Y-a-t-il  des  nerfs  speciaux  pour  la  douleur?" 

Ecv.  sci.,  Paris,  1897,  iv.  271-276;  viii,  402-404. 
Toll,  H.    "De  dolore."    Groningael,  1748. 
ToLLEY,  J.  E.    (173).     "The  Medical    Treatment  of   Pain  Not  of 

Gastric  Origin."     Am.  Med.,  Philadelphia,  1906,  xi,  57-60. 
Torrance,  Gaston  (577,  790).    "A  Case  of  Acute  Gastric  and  Duo- 
denal Dilatation  Treated  by  Gastroenterostomy,  with  Recovery." 

N.  Y.  Med.  Jour.,  Jan.  9,  1905. 
Treveltan,   E.   F.     "A   Case  of   Acute  Meningomyelitis."     Brain, 

1899,  xxii,  607. 
Treves  (74).    Lancet,  i,  18. 

(79).     "Intestinal  Obstruction."     Eevised  ed.,  1889,  297. 

Treves,  M.    (851).     "Eicerche  sulla  sensibilita   termica  delle  vane 

mucosa."     Archiv.  ital.  d.  biologia,  xxxvi    191. . 
Trevisanello.     "Alcune  considerazione  clmiche  interno  al  sintoma 

dolore."     N.  Leguria  med.,  Genoa,  1873,  xviii,  449,  465. 
Trieberg,  a.  H.    "Sciatic  Pain  as  an  Orthopedic  Symptom."     Ohio 

Med.  Jour.,  1909,  v,  17. 
Tripier,  p.     "Pathogenic  d'une  classe  peu  connue  d'affections  dou- 

louieuses;  algies  centriques  et  reflexes."     Archiv.  gen.  de  med., 

Paris,  1869, 1,  399-414. 
Tunnicleff,  F.  H.    (546).     "A  Case  of  Fracture   Dislocation  of 

Spinal  Column,  with  Lesion  of  the  Cord."     Brain,  1893,  xvi, 

445. 
Upham,  H.  L.    "Pleasure  and  Pain."     Boston,  1891. 


864  .  BIBLIOGRAPHY 

Vail,  D,  T.    "Ocular  Migraine."    Jour.  Ophthalmology,  Otology  and 

Laryngology,  No.  10. 
Valentine    (507).      "Physiologic    Pathology    of    the    Nerves,"    ii, 

240. 
Van  Buren  and  Keyes.    "Genitourinary  Diseases."    1874,  268. 
Van  den  Burg,  W.  H.   (966).     "Abdominal  Pain."     N.  Am.  Jour. 

Homeopath.,  N.  Y.,  1905,  liii,  583-590. 
Vance  (1122).    Clinic,  Chicago,  1907,  xxviii,  540-544. 
Van  Geehrichten  (103,  433).     "Les  voies  ascendantes  du  cordon 

lateral  de  la  moelle  epiniere."     Le  ne  vrasee,   1901,   iii;  Sys- 

teme  nerveux,  i,  460. 
Van  Ehtn,  D.    "De  dolore."    Harderovici,  1767. 
Van    Sweringen,   B.    (198,    368).      "Clinical    Importance    of   Ab- 
dominal Pain  in  Eelation  to  Intrathoracic  Lesions."    Fort  Wayne 

Med.  Jour.  Mag.,  Jan.,  1907,  xxviii,  10-13. 
Verger,  H.      "Formes   cliniques   et   diagnostiques  des  neuralgies." 

Gaz.  hebd.  de  sci.  med.  de  Bordeaux,  1908,  xxix,  385-393. 

.     "Neuralgies  sciatiques."     Med.,  Paris,  1908,  xix,  242-244. 

ViLLANi,  G.     "Le  sintoma  dolore  nelle  diagnosi  difficile  od  indeter- 
minate."    Riv.  crit.  di  din.  med.,  Firenze,  1901,  ii,  297,  313, 

329,  349. 
ViTEK,  V.     "Further  Observations  on  Hyperesthesia  in  the  Eegion 

of  the  Sympathetic  Ganglia."     Rev.  v.  neurol.  psychiat.  fys.  a 

dsetet  therap.  v.  Praze,  1909,  v,  218-222. 
Vlaerdingerwoud,  J.    "De  dolore.  in  genere."    Lugd.  Bat.,  1710. 
VoLKMAN    (413).     "Nerven-Physiologie."     Wagner's   "Handworten- 

buch  der  Physiologic,"  ii,  571. 
Vorschutz.     "Hyperalgetische  Zonen  bei  Shadel  und  Gehirnverletz- 

ungen."    Deutsche  Zeitschrift  f.  Chir.,  1907,  Ixxxviii. 
Vosper.     "Toothache."     Lancet,  Mar.  18,  1905,  712. 
Wadlington,  W.  J.   (59).     "Referred  Pain  and  Its  Significance." 

Ab.  in  J.  A.  M.  A.,  Dec.  14,  1907,  xlix,  2031. 
Wagner,  J.     "Theoretische-praktischer  Beitrage  zur  Lehre  von  den 

Schmerzen."    Med.  Jahrb.  des  k.  k.  osterr.  Staates,  Wien,  1841, 

XXV,  181,  309. 
Walker,  T.  D.     "Hilton  on  Rest  and  Pain."    Maritime  Med.  News, 

Halifax,  1904,  xvi,  127-132. 
Wallenberg,  V.  (440).     "Sekundare  sensible  Bahnen."    Anat.  An- 

zeiger,  1900,  xviii. 
Walsh  (890).    "So-called  Rheumatisms."    Medical  News,  Feb.  18, 

1905,  300-302, 


BIBLIOGRAPHY  865 

Walton.     "Constitutionelle  Kopfschmerzen."     J.  A.  M.  A.,  1906, 
No.  19. 

(547).    "Fracture  of  Spine."    Internat.  Clinics,  1908,  v,  1. 

(517).     "Occupation   Neurosis."     Internat.    Clinics,   iv,    17th 

series. 

Warbasse,  J.  P.     "Abdominal  Pain,  Its  Diagnostic  Significance  in 

Surgical  Diseases."     Am.  Jour,  of  Surg.,  Aug.,  1911. 
Warrington  and  Griffith    (4:14).     "On  the  Cells  of  the   Spinal 

Ganglia  and  on  the  Eelationship  of  Their  Histological  Structure 

to  the  Axonal  Distribution."    Brain,  1901,  297-325. 
Watkins.     "Headaches  of  Ocular  and  Nasal  Origin."    Jour.  Arkan- 
sas Med.  Soc,  Dec,  1911,  viii.  No.  7. 
Watson,  L.   F.     "Prevention  of  Post-operative   Pain  and   Shock." 

Jour.  Okla.  State  Med.  Assoc,  Nov.,  1911. 
Webber,  G.  G.     "Electricity  as  a  Means  of  Relieving  Pain."     Am. 

Psych.,  N.  Y.,  1875-76,  iii,  210-212. 
Weber    (386).      "Contribution    a   I'etude   de    la   sclerose."      Paris, 

1883. 
Weber,  E.  H.   (411,  552).     "Der  Tastsinn  und  das  Gemeingefiihl." 

Wagner's   "Handorterbuch   d.   Physiologic,"   1846,  iii,  Abth.   2, 

118,  481. 
Westbrook  (622).     "The  Growing  Pains  Fallacy."    Brooklyn  Med. 

Jour.,  1905,  xix,  196-199. 
Whitaker,  E.  H.  E.     "Concerning  Cranial  Neuralgias."     (Trigemi- 
nal neuralgia.)     British  Dent.,  London,  1909,  xxx,  193,  209. 
White,  B.  C.   (486).     "Hyperalgesia  of  the  Skin  Overlying  Active 

Lesions  in  Pulmonary  Tuberculosis."     Archiv.  Int.  Med.,  July, 

1909,  iv,  1-7. 
White,  H.    (545).     "Abscess  Vertebra  Showing  Sensory  Lesions." 

Brain,  1893,  xvi,  381. 
WiCHMAN,  EoLPH  (406).     "Die  Eiickenmarksnerven  und  ihre  Seg- 

mentbeziige."     Berlin,  1900. 
WiGGiN,  F.  H.   (28,  90,  758,  958).     "Abdominal  Pain  of  Intestinal 

Origin."     Lancet,  London,  1904,  ii,  213-215;  N.  Med.,  N.  Y., 

1904,  xcviii,  165-175;  Med.  News,  1904,  Ixxxiv,  289-293. 
Wiggins,  F.  L.  (44,  1053).    "The  Logic  of  Abdominal  Pain."    J.  A. 

M.  A.,  June  22,  1906,  xlvi,  1966;  Int.  Jour.  Surg.,  N.  Y.,  1906, 

xix,  302-305. 
WiLAMOWSKi,  B.  J.    (189).     "Zustand  der   Sclrmerzempfindlichkeit 

der  Haut  bei  inneren  Krankheiten."    Berliner  klin.  Woch.,  Sept. 

30,  1907,  xliv,  No.  39.    Ab.  in  J.  A.  M.  A.,  Nov.  2,  1907,  xlLx, 

No.  18,  1563-1572. 


866  BIBLIOGRAPHY 

Wilbur,  E.   L.     "Significance   of   Pelvic  Pain."     California   State 

Jour.  Med.,  Dec,  1911,  ix,  No.  12. 
WiLKixs,  J.  A.,  and  Blockham,  E.  J.   (93,  258).     "On  the  Treat- 
ment of  Pain  and  Pyrexia."     Med.  Eep.,  London,  1896-97,  vii, 

145-147,  177-179. 
WiLKiNSOX,  0.     "Basilar  Headaches   and   Neurasthenia  of   Ocular 

Origin  Not  Usually  Eecognized."    Virginia  Med.  Semi-monthly, 

Feb.  23,  1912,  xvi.  No.  22. 
Williams,  E.  T.     "Diseases  of  the  Spinal  Cord."     London,  1908, 

432,  7  pi.  (Hodder  and  Stoughton). 
Willis,  P.  W.  (587).    "The  Significance  of  Abdominal  Tenderness." 

Northwest  Med.,  Seattle,  1906,  iv,  118-121. 
Wilms.      "Hyperalgetische    Zonen   bei   Kopfschiissen."      Mitteil.    a. 

Grenzgebiet  d.   Med.  u.   Chir.,   1903,  ii;   Berliner  klin.   Woch., 

1904,  No.  36. 
Wilms,  M.    "Die  Schmerzempfindung  innerhalb  der  Biiuchhohle  und 

ihre  Bedeutung  fiir  die  Diagnose."     Med.  Klin.,  Berlin,  Jan.  1, 

1911,  vii.  No.  1. 
Wilson,  T.  Stagey  (896).    "Pain  in  Mucous  Colitis."    British  Med. 

Jour.,  July  10,  1909,  73. 
Wilson,  Thomas   (28,  361).     "The  Medical  Treatment  of  Uterine 

Fibroids  and  Its  Limitations."    Lancet,  Dec.  30,  1905,  1886-90. 
WiNDSCHEiD,  F.     "Die  Diagnose  und  Therapie  des  Kopfschmerzes." 

Halle,  1909. 
■  (148).    "Ueber  hysterische  Schmerzen  und  deren  Behandlung." 

Monatsschrift  f.  Geburtshilfe  u.  Gynakologie,  1895,  478-493. 
WiXKLER  (57,  1121).     "Die  lokale  Herabsetzung  des  Schmerzsinnes 

durch  den  elektrischen  Strom."     Monatshefte  f.  prakt.  Dermat., 

Hamburg,  1907,  xlv,  284-294.     Ab.  in  J.  A.  M.  A.,  Nov.  23, 

1907,  xlix,  1755. 
Winter  (903).     "Gynecologic  Diagnosis."    Am.  trans,  by  Clark. 
Wise,  W.  D.    "Abdominal  Pain."     Jour.  Alumni  Assoc.  Coll.  Phys. 

and  Surg.,  Baltimore,  1908-09,  xi,  18-21. 
WiTHERSPOON,  F.  C.  (125,  908).    "Significance  of  Pain  in  the  Upper 

Abdomen."    Virginia  Semi-monthly,  Eichmond,  Aug.  23,  1907- 

08,  xii,  217-221. 
WiTMER,  L.  (37,  283,  527).    "Pain."     Twentieth  Century  Practice, 

1897,  xi,  903-945. 
Wood,  J.C.    "Three  Cases  of  Eeferred  Pain."    Hahnemann  Monthly, 

Philadelphia,  1909,  xliv,  587-594. 
Wood,  J.  W.     "Occurrence  of  Headache  and  Pain  in  Nasal  Condi- 
tions."   Med.  Press  and  Circular,  London,  Nov.  9,  1910. 


BIBLIOGRAPHY  867 

WuxDT^  H.  (458,  535).  "Grundziige  der  physiologischen  Psycholo- 
gie."  5te  Auflage,  ii,  1;  -ite  Auflage,  i,  111-112;  3te  Auflage,  i. 
115-116,  290,  508-509. 

(508).     "Lehrbuch  der  Physiologie  des  Mensclien,"  503,  1074. 

WtJRTZEX.  '"Eeferred  Pain  in  Forty-four  per  Cent,  of  Three  Hun- 
dred and  Seventy-six  Cases  of  Tuberculosis  of  the  Lungs."  Zeit- 
schrift  fiir  Tuberkulose,  1906,  viii,  290. 

WuTZEE^  C.  W.    "Ueber  ortliche  Anwendung  von  betiiubenden  Mitteln 

zur  Schmerzstillung."'     Rheinisehe  Monatshefte  f.  prakt.  Aerzte, 

Koln,  1851,  V,  159-162. 
Xenophox's  Anabasis  (340).     "Wound  of  Abdomen."     See  Index 

under  JSTikarchos. 
Yates^  H.  W.     "Abdominal  Pain,  Its  Clinical  Significance."     Jour. 

Mich.  Med.  Soc,  Detroit,  1908,  vii,  237-243. 
Yawger  (772).    J.  A.  M.  A.,  1,  No.  17,  1310. 
Y^'eeo^  J.  B.    "Why  Is  Pain  a  Mystery  ?"    Contemp.  Review,  London, 

1879,  XXXV,  630-647. 
Young  (908).    British  Med.  Jour.,  Apr.  14,  1906. 
Y^ouNG,  Hugh  (733).    Osier's  "System  of  Medicine,"  iv,  331. 
Ziehen.    "Krankheiten  des  Gehirns,"  in  Ebstein-Schwalbe's  ''Hand- 

buch  der  praktischen  Medizin."     Stuttgart,  1905. 

(462).     "Leitfaden   der  physiologischen   Psychologic."     Jena, 

1911,  5te  Auflage,  53  (Gustave  Fischer). 

Zielinski,  C.  (495).    "Pneumonie  simulant  I'appendicites."  Archiv. 

de  med.  des  enfants,  Dec,  1902,  741. 
ZiEMSSEN,   0.      "Heilung  der  Ischias."     Ztschr.   f.   Phys.   u.   diet. 

Therapeutics,  Leipzig,  1907-08,  xi,  678-681. 


INDEX 


Abdomen,  divisions  of,  for  localiza- 
tion purposes,  395,  396 

lesions     of,     causing     epigastric 
pain,  396,  397,  398 

localizing  center  for  pain,  307 

muscular  inflammation  of  wall  of, 
361 

shoulder  pains  in  lesions  of,  392 

use  of,  in  estimating  susceptibil- 
ity of  patient,  124 

zones  of,   395,  396 
Abdominal     adhesions,     causes    of, 
368,  369 

groups  of,  369 
Abdominal  incisions,  415 
Abdominal    inflammation,    thoracic 

breathing  in,  127 
Abdominal    pain,    absence    of,    in 
lesions  of  abdomen,  416 

areas  of  tenderness  with,  394 

associated     with     arteriosclerotic 
condition  of  arteries,  121 

causes  of,  307 

characteristics  of  intestinal  lesions 
causing,  469 

classification  of,  360 

concentric  palpation  in,  394 

conditions  associated  with,  413 

diagnosis  of,  390 

differential  diagnosis  of,  414 
table  of,  376,  412 

distinguished     from     hysterical 
pain,  414 

due  to  biliary  disease,  401 

due  to  contraction  and  dilatation, 
390 

due    to    diaphragmatic    traction, 
307 


Abdominal  pain,  due  to  extrav- 
asations of  septic  material, 
400 

due  to  functional  processes,  400 

due  to  incisions,  415 

due  to  intestines,  401 

due  to  irritation   of  the  sympa- 
thetic fibers,  399 

due  to  new  growths,  362 

due  to  pancreatic  disease,  401 

due  to  passive  dilatation,  390 

due  to  perforation  in  typhoid,  402 

due   to   shock,   400 

due  to  the  stomach,  401 

due  to  traction  on  the  mesentery, 
390 

effect  of,  on  diaphragm,  394 

epigastric,  396 

examination  for,  394 

forms  of,  408 

functional,  409 

gastralgia,  409 

hysterical,   360 

in  bowels,  372 

in  cysts,  399 

in  hernia,  371 

indicanuria  with,  414 

intestinal    lesions    suggested    by, 
470 

lesions  causing,  408,  409 

localization  of,  394 
organ  producing,  395 

muscular  layer  of  wall  as  seat  of 
(McKenzie),  360 

myalgia,  362 

nature   of,   390 

neuralgia,  361,  409 

neuritis  of  intercostal  nerves,  362 


869 


870 


INDEX 


Abdominal  pain,  objective,  360 

of  the  peritoneum,  362 

of  pneumonia,  392 

organs  causing,  408 

points  of  reference  of,  391 

polyuria  with,  414 

post-operative,  415 

posture  in  diagnosis  of,  406 

presence  of,  in  neurasthenics,  409, 
410 

pressure  in,  406,  407 

referred,  307,  391,  392 

to  extra-abdominal  regions,  416 

reflected,  391,  392 

regional,  393 

relationship     of,     to     defecation, 
401 
to  ingestion  of  food,  400,  401 
to   menstruation,   401 

rigidity  of  muscles  with,  413 

skin  as  seat  of,  360 

spasm  of  muscles  with,  413 

subjective,  360 

sympathetic,  393 

tenderness,    maximum   points   of, 
393 

toxemia  with,  414 

transferred,  392 

transmission    of,    in    the     peri- 
toneum   (Lennander),  363 

visceromuscular  reflex  with  (Mac- 
kenzie), 413 
Abdominal  protective  position,  126 
Abdominal  tenderness,  403 

causes  of,  404 

indications  of,  404 

in  tubal  disease,  720 

means  of  determining :  percussion, 
404 
palpation,  405 
Abdominal    visceral    disease,    pain 

perception  in,  377 
Abscess,  "closed"  extradural,  338 

extradural.     See   Extradural   ab- 
scess. 

gas,  338 


Abscess,  hepatic,  553 

in   areola,   from  fissured   nipple, 

258 
ischiorectal,  509 

of  the  brain.     See  Brain  abscess, 
of   the   hip   joint,    intraarticular, 

244 
of  mastoid  process,  336 
of  the  ovary,  751 
of  the  spleen,   601 
"open"  extradural,  338 
perianal,  512 
perisinus,  338 
peritonsillar,  340,  351 
retrophaiyngeal,  352 
Adenoid  vegetation  of  nose,  343 
Adenolij^omatosis,  symmetiical,  224 
Adhesions,    abdominal,    causes    of, 
368,  369 
groups  of,  369 
after  intussusception,  498 
appendieial,  519 
epigastric  pains  from,  398 
from  tubal  inflammation,  746 
gastric,  369 
hepatic,  553 
intestinal,  370 

distention  due  to,  492 
of  the  bladder,  684 
of  the  gall   bladder,  563 
of  the  omentum,  368 
of  the  ovary,  752,  754 
pelvic,  370 

point  of  tenderness  in,  405 
perigastric,  459 
perihepatitis  causing,  560 
peritoneal,  371 

increased  pain  by  tension,  368 
nature  of  pain  from,  367,  368 
visceral,  absence  of  pain  in,  368 
Adiposa  dolorosa,  associated  condi- 
tions of,  225 
differentiated,   from   other  forms 
of  adiposity,  224 
from  sciatica,  168,  169 
fatty  areas  of,  224 


INDEX 


871 


A  d  i  p  o  s  a    dolorosa,    hypophyseal 
symptoms,  225 

pain  as  a  feature  of,  224 
Adiposis   cerebralis    (of   Frohlich), 

224 
Adiposity,  forais  of,  224 

tuberosa  (of  Anders),  224 
Aditus   laryngis,   tuberculous   affec- 
tions of,  354 
Adrenals,   hemorrhage   as   cause  of 

pain  in,  259 
Akinesia  algera,  219 
Alcohol,  neuralgia  due  to,  142 
Algometers,  68 

in  measuring  pain,  130,  131 
Alimentary  tract,  pains  of,  418 

referred  pains  in,  425 
Alkalies,  uses  of,  119 
Amblyopia,    concentric    contraction 

of  %asual  field  from,  135 
Amputated    limb,    imagined    sensa- 
tions in,  104 

projection  pain  in,  103 

visualisation  of,  103 
Anal  fissure,  510 

acute  pains  of,  511 

description  of  pain  in,  511 

reflex  pains  of,  512 
Anemia,  back  pains  due  to,  304 

chronic,   of  the   brain,   181 

pernicious.     See   Pernicious 
anemia. 
Analgesia,  61,  62,  63 

area  of  distribution  in  a  hysteri- 
cal subject,  78 

central,  61 

endogenous,  61 

exogenous,  61,  63 

extiinsic,  63 

peripheral,    61 

toxic,  62 

tabes  producing,  66 

voluntaiy,  62,  63 
Anemic  headaches,  272 
Anesthesia,  61,  63 

by  freezing,  QQ 


Anesthesia,    by    interference    with 
pain  perception  areas,  64 

by  ischemia,  66 

by   pressure,  64 

cord  tumor  accompanied  by,  65 

dissociation    of    pain    and    touch 
under  incomplete,  34 

electric  current  causing,  65 

lesions   within  nerves  producing, 
66 

of  hysteria,  76,  77 

of  leg,  by  skull  fracture,  64 

paresis  causing,  65 

pei'ipheral  causes  of,  65 

pressure  in  nerve  sheath  produc- 
ing, 66 
on  a  nerve  trunk  producing,  66 

reflex  protective  action  in,  122 

severance  of  nerve  pathways  pro- 
ducing, 65 

severance  of  posterior  roots  pro- 
ducing, QG 

syringomj'elia  causing,  66 

transverse  myelitis  causing,  66 
Anesthesia  dolorosa,  66 

in  neuralgia,  144 
Aneuiysm,   importance   of   pain   as 
a  symptom  in,  255 

neuralgia  from,  142 

of  arch  of  aorta,  803 

of  the  arteries,  254 

of  the  brain  arteries,  187 

pressure  indicating,  127 
Angina   pectoris,   associated  symp- 
toms of,  787 

character  of  pain  in,  784 

distingaiished  from  gastric  ulcer, 
451 

etiology  of,  783 

local  tenderness  in,  787 

location  of  pain  in,  785 

similarity  of,  to  aortitis,  250 

sjTnpathetic  pain  due  to,  103 
Animals,    sensation    in    the    lower 

forms  of,  1,  2,  3,  4 
Anus,  pain  in,  509 


872 


INDEX 


Anus,  pain  in  disease  of,  from  def- 
ecation, 117 
Aorta,  arteriosclerosis  of,  251 

inflannnatiou  of,  250 
Aortitis,  description  of  pain  of,  250 

time  of  onset  of,  251 
Aphasia,  from  tumors  of  the  fron- 
tal lobe,  184 
Appearance  of  patient  as  means  of 
measuring  intensity  of  pain, 
120,  125 
Appendicial    disease,    ingestion    of 
food  in,  116 
pain  from  defecation  in,  118 
transfen-ed  pain  in,  107 
Appendicial  inflammation,  aben-ant 

pains  with,  527 
Appendicial  pain,   distant,  519 
due  to  adhesions,  519 
due  to  inflammation,  517 
due  to  obstruction,  517 
left-sided,    527 
local,  516,  517 
referred,  516,  519 
reflex,  517,  521 
transferred,  516,  520 
varieties  of,  516 
Appendicitis,      colon      involvement 
with,  527 
constipation  with,  535 
differential  diagnosis  of,  537,  538, 

539 
increase  in  sensibility  to  pressure 

in,  536 
induction   of  pain  by  peristalsis, 

537 
interference  with,  motion  in,  535 
jarring  pain  from,  536 
nocturnal  pains  of,  111 
pain  from  motion  in,  117 
pain    induced   by    peristalsis   in, 

537 
pain  production  in.  symptoms  as- 
sociated with,  535 
posture  assumed  in,  536 
pressure  on  the  abdomen  in,  536 


Appendicitis,  rigidity  of  the  right 
rectus  with,  535 
sympathetic  pains  with,  527 
symptoms    associated    with    pain 

production  in,  535 
tenderness   in,    absence   of,   as    a 
symptom,  531 
as  a  symptom,  529,  530 
locations  of,  533 
points   of,  534 
varieties  of,  532 
Appendix,  adhesions  of,  519 
description  of,  514 
diffuse  pain  in,  515 
epigastric   pain  from  lesions  of, 

397 
hyperalgesia  in,  area  of,  527 

indications  of,  525 
hyperesthesia  in,  pointing  to  in- 
flammation of,  524 
inflammation  of,  517 

without  symptoms,  516 
obstruction  in,  causes  of,  517 
pain  in,  514 

vermiform,  diseases  of,  529 
Apraxia,  1S5 

Areas,  cutaneous,  relating  to  spinal 
cord  segments,  56 
indefinite,  of  pain,  48 
of  distribution,  of  hysterical  pain, 
78,  79 
of   lumbar   segments,    diagram 

of,  57 
of  nerves  from  lumbar  plexus, 

52 
of  nerves  from  sacral  plexus,  53 
of  sacral  and  lumbar  segments, 

diagram   of,  57 
of  sensoi-y  fibers,  51 
of   sensory   fibers  in   posterior 
root,  51,  54 
of  hyperalgesia,  69,  70 
of  maximum  tenderness  and  cord 

zones,  59 
of  pain   perception,   interference 
with,  64 


INDEX 


873 


Areas  of  peripheral  sensory  fibers, 
50,  51 
of  sensory  nerves,  47,  48 
of  tenderness,  72 
surface,  relating  to  visceral  dis- 
ease, 4,  5 
Arsenic,  neuralgia  due  to,  142 

terminal  anesthesia  by,  67 
Arterial  congestion,  273 
Arterial  pressure,  increase  of,  caus- 
ing headache,  272 
Arterial  system,  functional  activity 

of,  causing  pain,  249 
Arteries,  aneurysm  of  the,  254 

diseases  of,  causing  pain,  249 
Arteries,  inflammation  of,  250 
mesenteric,  embolism  of,  253,  254 

thrombosis  of,  253,  254 
thrombosis  or  obliteration  of,  248 
Arthralgia.     See  Joint  pains. 
Arthritis,  gonorrheal,  238 

symptoms  of,  235 
Arthrotomy,   in  intra-articular  hip 

joint  abscess,   245 
Ascending  path  of  sensory  fibers^  45 
Aspect  theoi-y  of  pleasure  and  pain, 

18 
Associated  pains,  90 
crossing  of  fibers  in,  92 
diffusion  of  stimuli  in,  92 
examples  of,  92 
hypochondriasis    not    manifested 

by,  93 
hysteria  not  manifested  by,  93 
in  neuralgia,  146 
physiological  relationship  between 

areas  of,  94 
relation    between    irritated    and 
sympathetic  points,  93,  94 
Asthenopic  disorders,  330 
Astigmatism,  330 

Atrophy,  of  liver,  acute  yellow,  561 
of  muscles,  in  neuralgia,  146 
resulting  from  pain,  135 
Auditory  canal,  external,   pain  in, 
333 


Autonomic  sympathetic  nervous 
system,  12 

Autosuggestion,  116 

Autosuggestive  sensations,  75 

Autotoxic  substances  causing  neu- 
ralgia, 141 


B 


Bacillus  pyocyaneus,  333 

Back,  localizing  center  for  pain  in, 

296 
Back  pains,  due  to  heart  and  aorta 
affections,  301 
due  to  hystei'ia,  304 
due  to  intestines,  302 
due  to  kidneys,  302 
due    to    liver   and   gall   bladder, 

302 
due  to  lung  affections,  300 
due  to  menstruation,  303 
due  to  pregnancy,  303 
due  to  spinal  cord  lesions,  207 
due  to  static  foot  errors,  304 
due  to  stomach  affections,  301 
due  to  uterine  disorders,  726 
due  to  visceral  lesions,  208 
in  anemia,  304 

indications  from,  in  different  re- 
gions, 312,  313,  314,  315 
muscular,  296 

in  myalgia,  297 
of  chlorosis,  304 
over  the  coccyx,  300 
refeiTed,   300 
from  genito-urinary  organs,  304 
from  ovary,  303 
from  pancreas,  303 
from   spleen,   303 
from  uterus,  303,  304 
rheumatic,  296 
vertebral,  299 
Bacteria,    productive    of    muscular 

pain,  218 
Belladonna,  terminal  anesthesia  by, 
67 


874 


INDEX 


Bile  duet,  twist  of,  from  liver  dis- 
placement, 559 
Biliary  cirrhosis,  554 
Biliary  colic,  ingestion  of  food  and 
drink,  effect   of,   case   cited, 
574,  575 
Biliary  passages,  cancer  of,  577 
Bladder,    adhesions    encompassing, 
684 

anatomy  of,  672 

cord  zones  in  relation  with,  674 

diseases  of,  causing  pain,  676 

distention  of,  684 

foreign  bodies  in,   691 

general  considerations  of,  672 

inflammation  of.     See  Cystitis. 

nerve  supply  to,  672 

rupture  of,  685. 

tuberculosis  of,  690 

tumors  of,   689 
Bladder   disease,    associated   symp- 
toms of,  682 

differential  diagnosis  of,  683 

tenderness  in,  681 
Bladder    lesions,    differential    diag- 
nosis of,  686 
Bladder  pains,  causes  of,  676 

character  of,  678 

cold  air,  effect  of,  on,  681 

diseases  causing,  683 

drugs,  effect  of,  on,  681 

food  and  drink,  in  relation  to,  681 

location  of,  678 

position  of  patient  in,  680 

production  of  factors  influencing, 
681 

reference  areas  of,  675 

reflected,   679 

time  of  attacks  of,  680 

urinai-y,    relation    to    motion    of, 
681 
Bladder  tuberculosis,  associated 
symptoms  of,  691 

causes  of  pain  in,  690 

character  of  pain  in,  690 

location  of  pain  in,  691 


Bladder  tuberculosis,  production  of 

pain  in,  factors  influencing, 

691 

time  of  pain  in,  691 

Blood,  changes  in,  causing  pain,  247 

decreased  alkalinity  of,  causative 

factor  of  pain,  28 
diminution  of  supply  of,  causing 

pain,  248 
diseases  of,  248,  249 
increased  supply  of,  causing  pain, 

247 
Raynaud's  disease  of,  248 
Blood    pressure,    elevation    of,    in 
labor,  121 
in  measuring  intensity  of  pain, 
120 
hyperemia  consequent  upon  varia- 
tions in,  62 
increase  of,  251 

sudden    alterations    of,    causing 
pain,  26 
Blood  supply,  determining  suscepti- 
bility of  an  organ  to  pain, 
113 
Blushing,  124 

Bones,  cause  of  pain  from  motion 
of,   117 
changes  in  structure  of,  231 
freedom  from  pain  in,  113 
lesions  of,  differentiated  from  in- 
durative headache,  267 
from    those    of    the    overlying 
structure,  226 
Bone  pains,  character  of,  228 
continuous,  227 

diagnostic  value  of  diurnal  varia- 
tion in,  228 
differential     diagnosis    of,     from 
bursitis,  233 
from  hysteria,  234 
from  neurotic  ostalgias,  233 
general  considerations  of,  226 
generalized,  232 
in  carcinoma,  233 
in  chloroma,  233 


INDEX 


875 


Bone  pains,  in  hematopoietic  system 
lesions,  233 
in   leontiasis  ossea,   233 
in  lymphadenoma  ossium,  233 
in  myeloma,  233 
in  osteitis  deformans,  233 
in  sarcoma,  233 
in  spurs,  233 
localized,  228 

in  contusions,  230 
in  fracture,  229,  230 
in  new  growths,  230 
in  periosteal  lesions,  229 
in  traumatism,  229 
pressure,  intermittent,  227 
septic  involvement  in,  231 
spontaneous,   intermittent,   227 
syphilitic,    dull   aching   chai-aeter 
of,   228 
nocturnal  aggravation  of,  228 
tuberculous  nocturnal  aggravation 

of,  228 
types  of,  227 
Bony    pi'ocesses,     neuralgia    from, 

142 
Bowel,  colic  of,  gas  with,  486 
distention  of,  491 
inflammation  of,  484 

involvement  of  adjacent  struc- 
tures   in,    486 
peristalsis  with,  486 
symptoms  of,  486 
tenderness  with,  486 
obstruction   of,    absence   of   pain 
in,  495 
causes  of,  492,  495 
pain  of,  areas  of  tenderness  in, 
372 
distinguished  from  hernia,  372 
due  to  distention  by  gas,   373 
Brachial  neuralgia,  147,  150 
associated  symptoms,  161 
bilateral  pain  in,  155 
brachial  plexus  as  seat  of,   150, 

151 
character  of  pain  of,  159 


Brachial  neuralgia,  differential  diag- 
nosis of,  155,  158 
table  of,  162,  163 
distribution    areas   of,    151,    152, 

153 
localization  of,  158 
location  of  pain  in,  159,  160 
tenderness   in,    161 
unilateral  pain  in,  155 
Brachial  plexus,  area  of  distribution 
of,  nerves  derived  from,  152 
description  of,  150,  151 
distribution  areas  of  cords  com- 
posing, 155 
of  cutaneous  nerves  of  upper 
limbs,   154 
neuralgia   from    lesions   in,    150, 
151 
Brachialgia,  brachial  neuralgia,  159 
Brain,  abscess  of,  as  cause  of  head- 
ache, 271 
ditferential   diagnosis    of,    195, 

196 
headache  and  other   symptoms 

of,  181,  182,  190,  191 
origin  of,  181 
aneurysm  of  arteries  of,  187 
hemorrhages,     differential     diag- 
nosis of,  196 
pain  in  legs  as  forerunner  of, 
305 
hypei'emia  of,  181 
metabolism,     disturbance    of,    in 

hysteria,  77 
pain  in  diseases  of,  140 
parasites  of,  187 
syphilis  of,  188 

substance,   diseases  of,   unaccom- 
panied by  headaches,   178 
headaches   originating  in,   176, 
177,  178,  179 
syphilis  of,  differential  diagnosis 

of,  196 
tumor  of,  causing  headache  by  in- 
tracranial pressure,  270 
diagnostic  symptoms  of,  270 


876 


INDEX 


Brain,  differential  diagnosis  of,  195, 
197 
headache  and  other  symptoms 
of,  182,  190,  191 
tumors  of  the  base  of,  186 
Break-bone    fever,    backache    -with, 

298 
Breast,  carcinoma  of,  259 
diseases  of,  table  of,  260 
pains,  correlation  through  nervous 
system   with   uterus   of,   715 
pains  in,  258 
Bright's  disease,   ulceration   accom- 
panying, 509 
Bronchitis,  acute,  795 
Burns,  ulcers  following,  489 
Bursitis,    distinguished    from    bone 
pains,  233 


Calculus,    progress    of    descent    of, 

610 
Calculus  pain,  character  of,  658 
etiology  of,  655 
location  of,  659 
Cancer,  of  the  biliary  passages,  577 
of  the  pancreas,  491 
of  the  stomach,  452,  453,  454,  455 
of  the  uterus,  744 
of  the  vulva,  756 
Carbolic   acid,    terminal   anesthesia 

by,  67 
Carcinoma,    effect    of   ingestion   of 
food  in,  116 
of  the  bones,  233 
of  the  breast,  259 
of  the  gall  bladder,  57 
of  the  larynx,  358 
of  the  rectum,  507 
of  the  stomach,  455 
Cardiac    disease,    differential    diag- 
nosis between  intercostal  neu- 
ralgia and,  781 
Cardiac  pain,  degeneration  of  car- 
diac gangUa  as  cause  of,  782 


Cardiac   pain,   mitral   regurgitation 
as  cause  of,  782 
raising    of    intraventricular    ten- 
sion as  cause  of,  782 
origin   of,   cardiac,   782 
gastric,  782 
Cardiospasm,  436 
cause  of  pain  in,  437,  438 
character  of  pain  in,  438 
contraction  in,  437,  438 
tension  pains  of,  437 
Caries  of  the  vertebral  canal,  210, 
211 
differential     diagnosis     of,    from 
neurasthenia     and     hysteria, 
210 
Catarrh,  of  middle  ear,  339 
Catarrhal   ulceration   of  the   intes- 
tines, 489 
Cartilage,  lack  of  pain  in,  113 
Caudal  lesions,  209 
Cell  areas,  superimposition  of,  for 

motion  and  sensation,  10 
Centers   of  memory,   for  pain,   24, 

25 
Centers  of  motion,  173 
of  perception,  for  pleasure  and 

pain,  21,  22,  23 
of  sensation,  173 
of  the  senses,  173 
Central  ganglion,  tumors  of,  185 
Central  nervous  system,  172 
anatomy  of,  173 

back   pains    connected   with,   208 
courses  of  fibers  of,  174 
diseases  of,  179 
origin  of  headache,  175 
thalamic  pains  of,  198 
tumors  of,   183 
Ceptors,  noci-,  29 

nocuous.    See  Noci. 
Cerebellar  abscess,  339 
Cerebellar  ataxia,  sj^nptoms  of,  185 
Cerebellum,  as  a  sensory  organ,  11, 
12 
tumors  of,  185 


INDEX 


877 


Cerebral    arteriosclerosis,    headache 
as  symptom  of,  274 

Cerebral    congestion,    as    cause    of 
headache,  272 
brain  fluid  increased  by,  272 
due   to    increased    arterial   pres- 
sure, 272 
predisposing  factors  to,  273 

Cerebral     hemorrhage,     differential 
diagnosis  of,   198 

Cerebral  tumor,  as  a  cause  of  head- 
ache, 269 

Cerebrospinal  fibers,  of  the  abdom- 
inal viscera,  378 

Cerebrospinal     fluid,     increase     of, 
causing  headache,  276 

Cerebrospinal  system,  development 
of,  32 

Cervical  lesions,  209 

Cervical  stenosis,  dysmenorrhea 
from,  729 

Cervicitis,  742 

Cervix,    spasmodic    contraction    of, 
730 
ulceration  of,  743 

Cervix  uteri,  sensibility  of,  709 

Cheeks,  pain  in,   418 

Chemical  action,  as  stimulus  of  sen- 
sation, 5,  6 

Chemical  changes,  pain  due  to,  27 

Chemical    irritations,    parenchyma- 
tous pains  from,  88 

Chemotropism,  1 

Chest,   localizing   center   for   pain, 
310 
pain  in.    See  Chest  pain, 
thoracic  walls  of,  760 

Chest  pain,  causes  of,  310,  760,  767 
diagnostic  points  on,   768 
from  diseased  lung,  767 
from  stomach  distention,  766 

Chest  wall,  localization  of  pain  in, 
767 

Childbirth,  normal,  738 

Chloral,  effect  on  blood  pressure  ele- 
vation, 120 


Chloroma,  233 

Chlorosis,   back   pains   of,   304 

symptoms  of,  181 
Choked  disc.     See  Papilledema. 
Cholangitis,  572 

catarrhal,   577 

suppurative,  577 
Cholecystitis,   569 

accompanying  gallstone,  576 

distinguished  from   gastric  ulcer, 
450 
Choroid,  pain  in,  328 
Cicatrices,  neuralgia  from,  142 
Ciliary  body,   pain   in,   325,  326 
Ciona  intestinalis,  2 
Circulation,   affection   of,    by  pain, 

134 
Circulatory  system :  arteries,  249 

blood  supply,  247 

veins,  255 
Circumflex  neuralgia,  147,  164 

causes  of,  164 

distinguished  from  rheumatism  of 
shoulder  joint,  164 
Cirrhosis,  biliary,  554 

of  the  liver,  552,  554,  556 
chronic  atrophic,  561 
Claudication,  intermittent,  251 
Clavicular  pains,  310 

in  extrauterine  pregnancy,  392 
Cocain,  effects  of,  119 

terminal  anesthesia  by,  67 

use  of,  106 
Coitus,  pain  in,  717,  756 
Cold,  causing  pain,  28 

neuralgic  pain  from  exposure  to, 
142 

physical  factor  of  pain,  118 
"Colds,"    productive    of    muscular 

pain,  218 
Colic,  436 

associated  with  uremia,  484 

causes  of,  223,  481 

constant  pain  in,  483 

due  to  contraction,  223 

due  to  overdistention,  223 


878 


INDEX 


Colic,  due  to  pressure,  223 

due  to  tension,  223 

due  to  traction,  223 

hypotheses  of  cause  of,  482 

intensity  of,  483 

intermittent  pain  in,  483 

intestinal,     differential    diagnosis 
of,  484,  485 
due  to  plumbism,  484 
without  bowel  lesion,  484 

location  of  pain  in,  482 

morphin  in,  125 

muscular  movement  in,  125,  126 

nocturnal  pains  of,  111 

onset  of,  482 

pain   of,   388 

posture  in,  126 

pressure  in,  126 

type  of  pain  in,  483 

variations  of,  222 
Colitis,  chronic,  502 

mucous,  503 

ulcerative,  501 
Colon,  displacement  of,  503 

distention  of,  504 

infective  states   of,  501 

inflammation  of,  501 

spasm  of,  502 

tumor  formation  due  to  displace- 
ment of,  505 
Colon  spasm,  description  of,  479 
Colonic  disease,  effect  of  ingestion 

of  food  in,  116 
Colonic    involvement,    in    intestinal 

pain,  500 
Concentric  palpation,  394 
Conducting  apparatus  for  pain,  29 
Conducting  fibers,   pressure  on,  29 
Congestion,  arterial,  273 

causing  affections  of  nerve  trunks, 
140 

cerebral,  as  cause  of  headache,  272 
Conjunctiva,   discomfort  from  tear 
secretions    in    irritations    of, 
324 

foreign  bodies  in,  324 


Conjunctiva,  pain  in,  322 
Conjunctivitis,  severity  of  pain  in, 
323 
stretching  of  the  lid  in,  324 
Consciousness,  4 
classes  of,  5 
loss  of,  in  anesthesia,  63 
from  emotion,  133 
from  pain,  132 
modifying  pain  production,  115 
objective,  5 
obtunded,  63 
senses  in  relation  to,  5 
subjective,  5 
Constipation,  colicky  pains  due  to, 
509 
neuralgic  pain  due  to,  509 
Contact,    dependence    of    sensation 

on,  6 
Contraction,    of    a    hollow    organ, 

25 
Contrary  innervation,  law  of  (Melt- 

zer),  388 
Contusions  of  bcnes,  230 
Conveying  channels  for  sensations, 
35 
deep,  37,  38 
epicritic,  37,  38 
protopathic,  37,  38 
superficial,  37 
Cofivolutions,  of  sensory  area,  10 
Copper,  as  cause  of  neuralgia,  142 
Cord,  pain  in  diseases  of,  140 
Cord  tumors,  95 

causing  anesthesia,  65 
Cord  zones,  areas  of  maximum  ten 
demess  of,  diagram  of,  59 
diagram  of,  55 
Cornea,  erosions  of,  324 
foreign  bodies  in,  324 
pain   in,   322 
perforation  of,  325 
sensibility  to  light  in  lesions  of, 

323 
tear  secretions  from  irritation  of, 
324 


INDEX    • 


879 


Corneal  herpes,  325 

Corneal  toxemia,  325 

Corneal   ulcers,   325 

Corpora   quadrigemina,   tumors  of, 

185 
Corpus  callosum,  tumors  of,  184 
Cortex,  absence  of  central  objective 
pain  in,  82 
differential  diagnosis  between  dis- 
eases  of   the   thalamus   and, 
203,  204,  205,  206 
interrelations  between  the  thala- 
mus and,  200 
Cortical    lesions,    unproductive    of 

pain,   82 
Cortical  tissues,  pain  receptors  lack- 
ing in,  82 
•  Cowper's   glands,   inflammation   of, 

703 
Cutaneous  areas,  relating  to  spinal 
cord   segments,   diagram    of, 
56 
Cutaneous    distribution    of    nerves, 

diagram  of,  56' 
Cutaneous     hyperalgesia,     relating 
to  areas  of  visceral  disease, 
54 
Cutaneous    sensorj'    nerve    supply, 

diagram  of,  49 
Cystalgia,  683 
Cystic  disease,  of  the  kidney,  645 

of  the  pancreas,  491 
Cysticercus  cerebri,  187 
Cystitis,  685 
associated  symptoms  of,  689 
attacks    of   pain    in,    factors   in- 
fluencing, 688 
character  of  pain  of,  685 
location  of  pain  of,  687 
referred  pain  of,  687 
tenderness  in,   688 
Cysts,  abdominal,  399 
of  the  breast,  259 
of  the  liver,  555 
of  the  spleen,  602 
ovarian,  399,  753 


D 


Defecation,  physical  factor  of  pain 

in,  117 
Deflected  pain.    See  Reflected,  104. 
Delayed  pains,  34,  111 
Delirium  tremens,  differential  diag- 
nosis of,  197 
Deranged  metabolism,  causing  neu- 
ralgia, 141 
in  influenza,  141 
in  senility,  141 
Deterioration,   physical,   causes  of. 

134 
Diagnosis,  care  in,  410 
errors  in,  410,  411,  413 
intensity  of  pain  a  factor  in,  114, 

120 
manual  reproduction  of  pain  in 
an  organ  in  forming  a,  132 
sensory   examination  in   forming 
a,  132 
Diaphragm,  crippling  of,  from  ab- 
dominal pains,  394 
pull  on,  from  liver  displacement, 
558 
Diarrhea,  with  intestinal  pain,  475 
Digestion,   physical  factor  of  pain 

in,  116 
Dilatation  of  pupils,  by  pain,  73 
causes  of,  125 
drugs  causing,   125 
means  of  measuring  pain  inten- 
sity, 120,  125 
Dilatation  of  the  stomach,  acute,  439 

from  pyloric  spasm,  438 
Diphtheria,  pains  of,  352 
Displaced    kidney.      See    Movable 

kidney. 
Displacement,  of  the  ovary,  749 

of  uterus,  726 
Dissociation  of  pain  and  touch,  32, 

33,  34 
Distention,  in  intussusception,  498 
of  the  bladder,  684 
of  the  bowel,  491 


880 


INDEX 


Distention,  of  the  liver,  551 
Distribution  areas,  of  nerves  from 
lumbar  plexus,  52 
of  nerves  from  sacral  plexus,  53 
of  peripheral  sensory  fibers,  50, 

51 
of  sacral   and   lumbar   segments, 

diagram  of,  57 
of  sensory  fibers,  51,  54 
Diurnal  pains,  110 
Diversion    of    attention    modifying 

pain  production,  116 
Dorsal  lesions,  209 
Dorsal  nerves,  diagram  of,  54 
Dreams,  subjective  pain  in,  75 
Dream  state,  pain  perception  in,  31 
Duct  disease,  effect  of  ingestion  of 

food  in,  116 
Ducts,  genital,  699 
Duodenal  ulcers,  489,  490 

distinguished   from    pyloric,    450 
ingestion  of  food  in,  116 
pain   of,   388 
Drugs,  analgesia  produced  by,  63 
pain  production  modified  by,  119 
predisposition    to    neuralgia    by 
use  of,  143 
Dysenteric  proctitis,  507 
Dysmenorrhea,  causes  of,  729 
differential  diagnosis  of,  757 
membranous,   730 
ovarian,   734 
prevalence  of,   728 
Dysphagia,     in     pharyngeal     affec- 
tions, 353,  354 
in    tuberculous   laryngeal    ulcers, 
358 
Dyspnea,   in   the   alimentary    tract, 
425 

E 

Ear,   acute  otitis  media  of,   335 
external,  332 
foreign    bodies    in    the    external 

auditory  canal  of,  334 
frost  bite  of,  333 


Ear,  furunculosis  of,  333 
herpes  of  drum  of,  335 
labyrinth  diseases  of,  340 
middle  ear,  catarrh  of,  339 
chronic  discharge  from,   336 
complications     of    disease    of, 

337 
disease  of,  335 
position  assumed  in  lesions  of, 

334 
pus  in,  337,  338 
suppuration  of,  337 
myringitis  bullosa,  335 
othematoma  of,  332 
otitis  externa  diffusa,  334 
otosclerosis,  339 
pain  in  diseases  of,  332 
in  drum  membrane  of,  335 
in  external  auditoiy  canal  of, 

333 
severity  of,  332 
perichondritis  of,  332 
reference  areas  for  pain  of,  335 
referred  pains  of,  340 
tumors   of,   333 
Ectopic  pregnancy,  epigastric  pains 

from,  397 
Eczema  introitus,  pain  caused  by, 

342 
Edema,  presence  of,  in  kidney  area, 

618 
Electric  current,   anesthesia  by,  65 
Electrical  reactions  causing  pain,  28 
Electricity,  faradic  current  of,  118 
measuring  pain  by,  130 
physical  factor  of  pain  in,   118 
static  spark  of,  118 
Embolism,  198 

differential  diagnosis  of,  196 
of  mesenteric  arteries,  253,  254 
Emotion,  14 

fatigue  resulting  from,  76 
loss  of  consciousness  from,  133 
Emotional  pains,  76 
Emotional  shock,  inducing  hysteri- 
cal pain,  79 


INDEX 


881 


Emotions,  modifying  pain  produc- 
tion,  115 
phenomena    accompanying,    132, 

133 
physical  results  of,  30 
Empyema,  acute,  diagnosis  of,  348 
diseases  in  body  related  to,  344 
headaches  arising  in,  343 
treatment  of,  348,  349 
Encephalitis,  from  electric  current, 

65 
Encephalitis   haemorrhagica,    differ- 
ential diagnosis  of,  196 
Endarteritis  obliterans.     See  Inter- 
mittent claudication,  248. 
Endocarditis,  differentiation  between 
acute    and    chronic    and    re- 
curring, 780 
Endogenous   analgesia,   61 
Endometritis,  730 

character  of  pain  in,  741 

diagnosis  of,  742 

dolorosa,  731 

involvement  of  adjacent  structures 

in,  741 
tenderness,    demonstrated    by    a 
sound,   741 
Endometrium,  fissured  state  of,  734 

sensibility  of,  709 
Endonasal  operation  for  neuralgia, 

350 
Endonasal  therapy,  uses  of,  342 
Endurance,  complaints  of  patients 
compared  with,  120,  123,  124 
Enlarged    uterus,    neuralgia    from, 

142 
Enteralgia,  476 

mistaken  diagnoses  of,  476 
Enteroptosis,  effect  of  constipation 

in,  118 
Enterospasm,  478 
causes  of,  480 

mistaken  diagnosis  of,  for  peri- 
tonitis, 480 
primary  pain  of,  478 
secondary  pain  of,  479 


Enterospasm,  tenderness  associated 

with,  483 
Eosinophilia,     differentiated     from 

acute  polymyositis,  221 
Epicritic  fibers,  37,  38 
Epieritic  system,  37,  39,  47 

of  Head,  12 
EpididjTuis,   pain   in,  699 
Epigastric  hernia,  375 

distinguished  from  gastric  ulcer, 
450 
Epigastric  pains,  character  of,  398 
lesions  causing,  396,  397,  398 
organs   causing,   397,    398 
suspected  lesions  in  diagnosis  of, 
398 
Epigastrium,   lesions   causing   pain 
in,  396,  397,  398 
organs  causing  pain  in,  397 
Epiphyseal  disease   (Marburg,  Jel- 

liffe),  224 
Equilibrium,  loss  of,  from  pain,  134 
Erythromelalgia,  252,  253 
Esophagus,    effect    of   ingestion    of 
food  in  disease  of,  116 
hyperesthesia  of,  424 
localization  of  pain  in,  425 
obstructions  of,  425 
pain  in,  424 
paresthesia  of,  424 
Esthesiometers,  68 
Ether,  effects  of,  119 
Evolution,  factor  in  relation  of  pain 

to  other  sensations,  31,  32 
Exogenous  analgesia,  61,  63 
Exposure    to    cold,    neuralgic    pain 

from,  142 
External  ear,  trauma  of,  332 
External  senses  in  the  fetus,  12 
Extracranial  head  pains,  265 
Extradural  abscess,   differential 

diagnosis  of,  195 
Extrahepatic  disorders,  557 
Extraneural    causes    of    neuralgia, 

142 
Extraparenchymatous  jDain,  557 


882 


INDEX 


Extrauterine  pregnancy,  differential 
diagnosis  of,  747 
pain  in,   746 
Extrinsic  analgesia,  63 
Extrinsic    factors    modifying    pain 

production,  116,  118 
Extroeeptor  sense    organs,  12 
Eye,  action  of  stimuli  on  retina  of, 
316 
asthenopic  disorders  of,  330 
astigmatism  of,  330 
consciousness   of   normal   retinal 

stimuli  of,  316 
diurnal  pain  of,  110 
fifth  nerve  the  seat  of  sensation 

in,  317 
intensity  of  pain  in,  316 
lacrimation,  317 
normal  retinal  stimuli  to,  316 
painful  stimuli  to,  316 
pain  ill,  diagnosis  based  on  locali- 
zation of,  318 
duration  of,  317 
etiology   of,   317 
ill  the  choroid,  328 
in  the  ciliary  body,  325 
in  the  conjunctiva  and  cornea, 

322 
in   the  iris,  325 
in  the  lids,  318 
in  the  optic  nerve,  328 
in  the  retina,  328 
in  sclerotic  coat,  327 
in   surroundings,   322 
localization  of,  318 
quality  of,  316,  317 
phthisis  of,  328 
reflex  phenomena  connected  with, 

318 
sensations    of,    disagreeable    and 

painful,  316 
significance   of   pam    in    diseases 

of,  316,  318 
tender  pressure  points  of,  322 
topography  of,  317 
trigeminus  irritation  of,  317 


Eye,   various   painful   disturbances 

of  (Bielschowsky),  331 
Eyelids,  as  source  of  pain,  318 

diagnostic  value  of  pain  localiza- 
tion in,  319 

herpes  zoster  of,  319,  320 

inflammation   of,   318 

neuralgia  of,   320 
Eye  muscle,  rheumatism  of,  328 
"Eye-strain,"  331 


F 


Facial   expression   indicating  pain, 

127 
Eacies,  Hippocratic,  127 
of  peritonitis,  127 
simulation  of,  128 
Factoi-s  modifying  pain  production, 

115 
Fallopian    tubes,    acut€    hyperemia 
of,   745 
inflammation  of.     See  Tubal  in- 
flammation, 
nerve  supply  to,  707 
pain  due  to  disease  of,  744 
tubal  conditions  causing  pain  in, 
744 
Fatty  tissues,  adiposa  dolorosa,  224 

pain  in,  224 
Fear,     vasomotor     collapse     from, 

133 
Febrile  herpes,  of  the  cornea,  320 

of  the  phaiynx,  352 
"Female  complaint,"  712 
Femoral  hernia,  375 
Fetus,  external  senses  in,  12 
Fibere,  motor,  174 

sensoi-y  conducting,  174 
Fibroids,   of  the   uterus,   744 
Fissure,  of  the  lips,  418 
of  the  nipple,  259 
of  the  tongue,  421 
Fitz's  rule  in  pancreatitis,  488 
Flat-foot,  radiated  pain  of,  to  knee, 
305 


INDEX 


883 


Flat-foot   disease,   neuralgia    (Mor- 
ton's)  in,  169 
Focal   symptoms   of  the  motor  re- 
gion, 183 
Folliculitis,  pain  caused  by,  342 
Foreign  bodies,  in  the  ear,  334 
neuralgia  from,  142 
sensation    of,    in    phaiynx    mth 
carcinoma  of  base  of  tongue, 
355 
Fracture,  229 

elicitation  of  pain  in,  230 
of  the  thorax,  764 
Freezing,  anesthesia  by,  66 
Frontal  lobe,  tumors  of,  184 
Functional  pains,  abdominal,  409 
Furunculosis,  causes  of,  333 
manifestations  of,  334 


G 

Gall-bladder,  adhesions  of,  563 

back  pains  refen'ed  from,  302 

colic  of,  562,  568 

carcinoma  of,  571 

defecation  in  disease  of,  118 

infection  of,  563 

inflammation  of,  563 

ingestion  of  food  in  disease  of, 
116 

location  of  pain  and  tenderness 
in  disease  of,  72 

new  growths  of,  571 

non-malignant  growths  of,  572 

overdistention  of,  562 

sarcoma  of,  571 
Gall-bladder  colic,  causes  of,  548 

distinguished  from  gall-duct,  578 

hysteria  distinguished  from,   572 
Gall  -  bladder     disease,     associated 
pains  of,  566 

etiology  of,  562 
Gall-bladder  pain,  diagnosis  of,  563 

differential  diagnosis  of,  564,  567 

diseases  causing,  568 


Gall-bladder  pain,  ingestion  of  food 
causing,  546 
radiation  of,  566 
refeiTed,   567 

reflex  tenderness  with,  567 
tenderness  in,  563 
Gall-bladder   and   ducts,   epigastric 

pains  from  lesions  of,  397 
Gall-duct  colic,  associated  symptoms 

of,  576 
Gall-duct  pain,  character  of,  573 
classiflcation  of,  573 
etiology  of,  572 
location  of,  573 
paroxysms  of,  573 
Gall-ducts,  obstruction  in,  572 
Gall-stone  colic,  575 

differential  diagnosis  of,  577,  579 
Gall-stone  pain,  549 
Gall-stones,  568 

cholecystitis  accompanying,  576 
nocturnal  pains  of,  111 
pei-sistence  of  pain  after  removal 
of,  142 
Galvanic  current,  effect  of,  in  neu- 
ralgia, 145 
Gangrene  of  the  viscera,  417 
Gas  abscess,  338 
Gasserian  ganglion,  neuralgia  from 

lesions  in,  148,  149 
Gastralgia,  431 

abdominal   pains   of,   409 
description  of,  432 
nervous,  distinguished  from  ulcer 
and    cancer,    452,    453,    454, 
455 
Gastric  adhesions,  diagnosis  of,  by 

pressure,  369 
Gastric  area,  reflexes  felt  as  pain  in, 

433 
Gastric  carcinoma,  causes  of  pain 
in,  457 
infection  in,  effect  of,  456 
local  disease  with,  458 
location  of,  456 
lymphangitis  with,  458 


884 


INDEX 


Gastric  carcinoma,  posture  of  pa- 
tient in  production  of  pain 
in,  456 
symptoms   of,   455 
Gastric  erosions,  442 
Gastric  mucosa,  excess  of  acids  on, 

effect  of,  435 
Gastric  pains,  appearance  of,  430 

associated  symptoms  of,  431 

character  of,  429 

confused  diagnoses  of,  due  to  re- 
flexes,  434 

distinction    between    gastric    and 
nervous  origin  of,  433 

duration  of,  430 

ingestion  of  food  in,  430 

previous  attacks  of,  431 

referred    pains    compared    with, 
461 

reflex  origin  of,  difficulty  in  dis- 
tinguishing, 434 

resistance  of  nervous  systems  to, 
433 

severity  of,  as  a  symptom,  429 
Gastric  ulcer,  absence  of  pain  in, 
443 

cause  of  pain  of,  443 

character  of,  444 

conditions  accompanjdng  and  as- 
sociated with,  448,  449 

diagnosis  of,  449 

diagnostic  symptoms  of,  458 

diet  producing  or  increasing  pain 
of,  447 

distinguishing  characteristics    of, 
444 

due  to  metastasis,  458 

histoiy  of,   448 

ingestion  of  food  in,  116 

lesions  mistaken  for,  450,  451 

location   of  pain   and  tenderness 
in,  72 

pain  after  cure  of,  142 

pain   of,  388 

pathology  of,  442 

position  in,  change  of,  447,  448 


Gastric   ulcer,    relative   position   of 
pain  to  site  of,  442 
tenderness   elicited   on   palpation 

in,  445 
tenderness  of,  445 
time  of  onset  of,  444 
Gastritis,  acute,  440 
character  of,  441 
subjective  pain  of,  440 
chronic,  442 
Gastro-intestinal    tract,    pains    of, 

diurnal,  110 
Gastromyalgia,  431,  432 
predisposing  causes   of,   diseases 

acting  as,  433 
symptoms  of,  432 
Gastroptosis,  431 
Generalized  pains,  93 
Geniculate  ganglion,  141 
Genital  organs,  female,  pain  in,  706 
sensibility  to  ordinary  stimuli, 
709 
male,  pains  in,  698 
Genital  pain,  sympathetic,  in  breast 
and  occiput,  715 
in   head,   715 

tendency  to,  on  left  side,  713, 714 

Genitalia,  female,  anatomy  of,  706 

differential  diagnoses  of,  725 

nerve  supply  to,  705,  706,  712 

Genito-urinary   organs,   back   pains 

referred  from,  304 
Gestures  indicating  pain,  128 
Girdle  pains,  95 
Glands,  general,  257 
mammary,    257 
mesenteric,  261 
thymus,  261 
thyroid,  261 
Glandular  oi'gans,  parenchymatous, 

pain  in,  87 
Glandular  stnictures,  257 
Glandular  tissues,  257 
Glans  penis,  pain  in,  704 

pain  in,  from  prostate  congestion 
and  inflammation,  701 


INDEX 


885 


Glaucoma,  acute,  329 
primary  and  secondary,  327 
source  of  pain  in,  318 
system  of  secondaiy,  325,  326 
Globes,  sunken,  329 
Glossitis,   422 

Glossodj'nia,  classification  of,  422 
Gonococcus    infection    of    shoulder 

joint,  304 
Gonorrheal  arthritis,  238 
Goi^t,  nocturnal  pain  of,  110 
Gouty  hip  joint,  distinguished  from 

sciatica,  245 
Gray  matter  cells,  nerve  fibei-s  aris- 
ing in,  42 
Groin,   incidents  of  pain  in,  from 

above  and  below,  96 
Growing  joints,  symptoms   of,  241 
Growing-out  pains  of  children,  229 
Gummata  of  the  rectum,  507 
Gummatous    masses,    similarity    of, 
to  tumors,  212 

H 

Habit  headache,  289 
"Habit  pains,"  80,  142 
Hair,  efi'ect  on,  of  neuralgia,  146 
excessive  weight  of,  as  cause  of 

headache,  265 
lack  of  pain  in,  113 
Happiness,     phenomena     resulting 

from,  133 
Head,  hj^peralgesic  zones  of,  290 
localizing  center  for  pain,  262 
overwork  on,  effect  of,  265 
pain  areas  in,  table  of,  263 
referred  pains  in,  264 
sense  of  pain  in,  264 
sense  of  pressure  in,  264 
Headache,  absence  of,  in  diseases  of 
the  brain  substance,  178 
associated  with,  aneurysm  of  the 
brain  arteries,  187 
brain  abscess,  181,  190,  191 
brain  tumor,  182,  190,  191 


Headache,  associated  with,  chlorosis, 

181 
chronic    anemia   of   the   brain, 

181 
diseases  in  general,  177 
h^'droeephalus  internus,  187 
hyperemia  of  the  brain,  181 
hysteria,  188,  190 
leptomeningitis  purulenta,  180, 

190,  191 
leukemia,  181 
neurasthenia,  189,  190 
pachymeningitis  interna  hsemor- 

rhagiea,  179,  180 
parasites  of  the  brain,  187 
pernicious  anemia,  181 
syphilis  of  the  brain,  188,  190 
tubei'culous  meningitis,  180 
tmnors,  183,   184,  185,  186 
diagnosis  of,  265 
constancy  of  intennittent  (peri- 
odic), 286 
in  brain  and  meningeal  disease, 

190 
of     recent     origin :     infectious 

disease,  281 

intracranial  lesions,  282 

toxemia,  282 

traimiatism,  282 
of    remote    origin :    alimentary 
tract,    284 

anemia,  285 

brain  tumors  and  abscesses, 
284 

cerebral  arteiitis,  285 

ears,  284 

eyes,  282 

kidney  lesions,  284 

nose,  283 

psychical  strain,  285 

sinus     disease     (accessory 
nasal),  284 
diagnostic  value  of,  as  a  symp- 
tom, 177,  178 
differential  diagnosis  of,  in  brain 

and  meningeal  disease,  195 


886 


INDEX 


Headache,   due   to   brain   substance 
affections,  176 

due  to  diseases  of  the  brain  and 
meninges,  192 

due  to  empyema  of  the  sinuses, 
343,  344 

due  to  hypertrophy  of  middle  tur- 
binate of  nose,  349 

due  to  irritation  of  organs  of  spe- 
cial sense,  277 

due  to  nasal  stenosis,  342 

due  to  nasal  tumors,  347 

due  to  obstructed  sinuses,  345 

due  to  sphenopalatine  diseases, 
345 

due  to  visceral  disease,  176 

external  influences  of,  in  diseases 
of  the  brain  and  meninges, 
193,  194 

frontal,  192 

hemicranic,  189,  190,  191 

indurative,  265 

intensity  of  pain  of,  in  diseases 
of  the  brain  and  meninges,  190 

localization  of  pain  of,  in  dis- 
eases of  the  brain  and  men- 
inges, 192 

lymphatic,  290 

origin  of,  175,  176 

postures  assumed  by  patients  suf- 
fering from,  290 

tension  of  pain  of,  in  diseases  of 
brain  and  meninges,  192 

therapy  for,  194 

toxemic,  271 

miilateral,  192 
Head  pain,  causes  of,  265 

due  to  the  alimentary  tract,  284 

due  to  anemia,  272,  285 

due  to  brain  tumors  and  abscesses, 
270,  271,  284 

due  to  cerebral  arteritis,  285 

due  to  cerebral  congestion,  272 

due  to  cerebrosjDinal  fluid  in- 
crease, 276 

due  to  the  ears,  284 


Head  pain,  due  to  the  eyes,  283 
due  to  hyper  blood-tension,  273, 

274 
due  to  increased  venous  j^ressure, 

274 
due    to    induration    of    muscles, 

265 
due  to  kidney  lesions,  284 
due  to  meningitis,  acute,  271 
due  to  metabolism,  268 
due  to  muscle  lesions,  265 
due  to  nasal  conditions,  283 
due  to  nerve  involvement,  268 
due  to  neuralgia,  268,   278 
due  to  neuritis,  268 
due  to  jDachymeningitis,  271 
due  to  psychical  strain,  285 
due   to    sinus    (accessory   nasal) 

disease,  284 
due  to  skin  lesions,  265 
due    to    toxic    irritation    of    the 

cerebral  cortex,  279 
headache,  265 
meningeal  changes  as  a  cause  of, 

functional,  269 
organic,  271 
origin   of,  extracranial,  265 

intracranial,  269 
projected,  268 
referred,   269 
referred    from   the    viscera,   290, 

291,  292,  293,  294,  295 
reflex,  269,  277 
rheumatic,  279,  280 
toxemic,  271 
Hearing,  protective  reflex  action  of, 

123 
Heari,  back  pains  due  to  affections 

of,   301 
dilatation  of,  781 
nerve  supply  to,   774 
Heartburn,  435 
Heart     disease,     diagnosis     of,    by 

means  of  location  of  i-eferred 

pain,  774 
general  considerations  of,  773 


INDEX 


887 


Heart  disease,  hyperalgesia,  impor- 
tance of,  as  a  symptom,  780 
hyperalgesic  zones  in,  location  of, 
777,   778 
prominence  of,  776 
pain  in,  775 
refeiTed  pain  in,  775 
Heart  pain,  intracardiac  lesions  as 

causes  of,  782 
Heat,  physical  factor  of  pain,  28, 

118 
Heel  pains,  306 

Hematoma  of  the  dura  mater.    See 
Pachymeningitis     interna 
haemorrhagica,  179 
Hematomyelia,  210 
Hematuric  nephralgia,  629 
Hemianesthesia,   18-1,    185 
impairment  of  senses  accompany- 
ing,  135 
transference  of,  in  hysteria  from 
one  side  of  body  to  other,  77 
Hemianopsia,  184 
Hemichorea,  185 
Hemicrania,  eye  pain  from,  321 
Hemicranie     headache,     189,     190, 

191 
Hemiplegia,  184,  185 
Hemopoitic  system,  lesions  of,  233 
Hemorrhage,  in  the  adrenals,  259 
of  the  brain.     See  Brain  hemor- 
rhage, 
cerebral.      See    Cerebral    hemor- 
rhage, 
easing  of  pain  by,  26. 
into    the    meninges,     differential 

diagnosis  of,  196 
pain  from,   in  body  cavities,   26 

in  body  tissues,  25,  26 
of  the  peritoneum,  367 
of  spinal  cord,  209,  210 
Hepatic  artery,  twist  of,  from  liver 

displacement,  559 
Hepatic  congestion,  551 

associated  symptoms  of,  552 
Hepatitis,  acute,  557 


Hepatoptosis,  558 

description  of  pains  of,  560 

posture  in,  effect  of,  559 

hereditary  migraine,  286 
Hernias,  bowel  pain  with,  372 

causes  of  pain  in,  371 

chronic  eases  of,  373 

diagnostic  criteria  of,  375 

distinguished    from    bowel    pain, 
372 

epigastric,  375 

femoral,  375 

increased  pain  by  tension  in,  368 

inguinal,  374 

mesentei-y,    as   a   factor   in   pain 
production,  372 

nature  of  pain  of,  371 

neuralgia  from,  142 

obstruction  due  to,  499 

of  the  ovary,  749 

omental,  373 

pain  as  a  symptom  of,  373 

peritoneal  irritation   with,   373 

pressure  on  ilioinguinal  nerve  by, 
372 

strangulated,  374 

umbilical,  374 
Herpes,  accompanying  sacral  neu- 
ralgia,  171 

corneal,  325 

febrile,  of  the  cornea,  320 
of  the  pharynx,  352 

neuralgic,  of  the  cornea,  320 

of  ear  drum,  335 

of  the  lips,  418 

of  the  pinna,  333 

of  the  tongue,  421 
Herpes  corneae  neuralgieus,  320 
Herpes  larjnigis,  357 
Herpes  zoster,  causes  of,  320 

character  of  pain  in,  319,  320 

distinguished      from     intercostal 
neuralgia,  165 

of  the  thorax,  763 

pharyngeal,   353,   354 
Heterosuggestive  sensations,  75 


INDEX 


Heterotoxie  substances,  causing  neu- 
ralgia,  141 
Hilton's  law,  220 
Hip  joint,  ankylosis  of,  244 

gouty  deposits  in,  245 
Hip  joint  abscess  (intra-articular), 

tension  pains  of,  244 
Hip    joint    affections,    rheumatism, 
305 
tuberculous,  305 
Hip     joint     disease,     distinguished 

from  sciatica,  168 
Hip  joint  pains,  240 
functional,  241 
in  inflammation,  241 
in  movement,  242 
radiating,  241 

weight-bearing,  241,  242,  243 
Hippocratic  facias,  127 
Hodgkin's  disease,  pain  in,  261 
Hourglass  stomach,   cause  of  pain 

in,  437 
Hunger  headache.  111 
Hydatid  disease  of  the  kidney,  646 
Hydatids  of  the  spleen,  602 
Hydrocephalus   (chronic),   differen- 
tial diagnosis  of,  187,  188 
Hydrocephalus  internus,   187 
Hydronephrosis,    associated    symp- 
toms of,   654 
causes  of,  653 
character  of  pain  of,  653 
differential  diagnosis  of,  656 
in  pregnancy,  654 
Hydrosalpinx,  744 
Hyoid,  reference  area  for  pain  in 

ear,  335  ' 

HyiDer  blood-tension,  headache  due 

to,  273,  274 
Hyperacidity,  relief  of,  from  alka- 
lies, 119 
Hyperacidity  pains  in  stomach.  111 
Hyi^eralgesia,  47,  61,  67 

accuracy  of  localization  decreased 

by,  70. 
appendicial,  525 


Hyperalgesia,  areas  of,  69,  70 
cutaneous,   relating   to   areas   of 

visceral  disease,  54 
dilatation  of  pupils  in,  69 
following  anesthesia  in  hysteria, 

77 
from  intercurrent  infection  of  vis- 
cera, 70 
in   reflected   pains  from  tbe  vis- 
cera, 106 
of  the  tongue,  421 
referred,  in  uterine  segments,  734 
temperature  and  touch  in,  35 
tenderness     ditferentiated     from, 

70,  71 
testing  of,  in  a  part,  68 
thoracic,  761 
zones  of,  in  the  skin,  69 
in  the  viscera,  384,  385 
Hyperalgesic  zones,  origin  of,  105 
Hyperchlorhydria,  434 
Hyperemia,  62 

of  the  brain,  symptoms  of,  181 
of  the  ovary,  749 
Hyi^eresthesia,   61,    68,    69,   70 
accuracy  of  localization  decreased 

by,  70 
appendicial,  524 
areas  of,  in  tissues,  69 

in    the    viscei'a    (Mackenzie's), 
385,  386 
attention  to  tissues  in  judging  of, 

68,  69 
following  anesthesia  in  hysteria, 

77 
from  influenza,  70 
in  neuralgia,  143 
of  uteiine  muscle,  731 
thoracic,  761 

transference  of,  in  hysteria  from 

one  side  of  body  to  other,  77 

Hypernephroma  of  the  kidney,  646 

Hj'perphoria,  eye  disturbances  due 

to,  331 
Hypersensitiveness  of  sense  percep- 
tive centers,  30 


INDEX 


889 


Hypertension  headaches,  associated 
symptoms  of,  275,  276 
distention    of   veins    of   brow   or 

scalp  in,   276 
general  consideration  of,  274,  275 
pressure  points  in,  275 
Hypertrophy  of  the  prostate,  701 
Hypnosis,    pain    perception    under, 
31 
subjective  pain  by,  75,  80 
Hypoalgesia  of  the  viscera,  385 
Hypochondriac  zones  of  the  abdo- 
men, 396 
Hypophyseal  symptoms  in  adiposa 

dolorosa,  225 
Hypophysis,  tumors  of,  186 
Hypotonia  of  globe,  327 
Hysteria,  back  pains  due  to,  304 
basis  of  pains  in,  76 
causes  of,  76,  77 
differential  diagnosis  of,  196,  197, 

199 
differentiated  from  caries  of  the 

vertebral  canal,  210 
differentiated    from    bone    pains, 

234 
distinguished    from    gall-bladder 

colic,  572 
importance  of  diagnosis  in,  76,  79 
pains  of,  216 
pressure  points  in,  79 
subjective    pain    caused   by,    74, 

75,  76 
symptoms  of,  188 
thoracic,  761 
Hysterical  headache,  289 
Hysterical  pains,   abdominal   pains 
considered  with,  414 
areas  of,  most  frequent,  79 
diagnosis  of,  79 

differentiated  from  real  pains,  79 
distinguished    from    pelvic    pain, 

710 
distribution  of,  78,  79 
emotional  shock  causing,  79 
in  children,  79 


Hysterical  pains,  negative  evidence 
in  diagnosis  of,  79 
positive  evidence  in  diagnosis  of, 

79 
relief  of,  by  suggestion,  79 
Hysterical    states,    explanation    of, 

76,   77 
Hysterics,  subjective  pains  of,  74 


Idiocy,  pain  perception  in,  62 
Imagination  of  pain,  31 
Incisions,  abdominal,  415 
Indican,  presence  of,  in  urine,  495 
Indicanuria  with  abdominal  pains, 

414 
Indifference,  state  of,  13 
Induration  of  head  muscles  as  cause 

of  head  pain,  265 
Indurative     headaches,      associated 
symptoms  of,  267 
description  of  pain  in,  265 
development   of   the   process   of, 

265 
diagnosed    from    bone    diseases, 

267 
diagnosed  from  meningitis,  267 
diagnosed  from  migraine,  267 
symptoms  of,  266 
Infancy,  causes  of  pain  in,  410 
negligible  diagnostic  value  of  pain 
in,  410 
Infarct  of  the  spleen,  601 
Infarction,  renal,   626 
Infection  causing  neuralgia,  143 
Infectious  diseases,  backache   as   a 

symptom  of,  298 
Inflammation,  appendicial,  517 
causing  affections  of  nerve  recep- 
tors, 140 
nerve  trunks,  140 
meningeal,      causing      headaches, 

271 
nasal,  pain  caused  by,  342 
of  abdominal  wall,  361 


890 


INDEX 


Inflammation  of  arteries,  250 

of  the  bladder,  685 

of  bones,  229,  231 

of  the  bowel,  484 

of  the  breast,  258 

of  the  cheeks,  418 

of  the  colon,  501 

of  the  esophagus,  424 

of  the  gall-bladder,  563 

of  the  hip  joint,  241 

of  the  joints,  235 

of  the  kidney,  629 

of  the  kidney,  acute.      See  Ne- 
phritis, 
chronic,   632 

of  the  lips,  418 

of  the  peritoneum,  364 

of  the  rectum,  506 

of  the  tongue,  421 

of  the  ureter,  670 

of  the  uterus,  740 

of  the  veins,  255 

of   viscera,    absence    of   pain   in, 
86,  87 

thoracic,   761 
Inflammatory  pain,  84 

beginning  of,  in  blood  vessels,  84 

cause  of  throbbing  in,  85,  86 

characteristics  of,  87 

dull  ache  in  later  stages  of,  86 

increased  size  of  lumina  of  ves- 
sels in,  84 

means  of  conveyance  of,  84 

reaction  of,  86 

systolic  pressure  increased  in,  85 
Inflammatory  states,   effect  of  mo- 
tion in,  116 
Influenza,  deranged  metabolism  in, 
141 

hyperesthesia  from,  70 

neuralgia  in,  141 

severe  neck  pain  of,  352 

slight   pressure   causing   painful 
reaction  in,  71 
Ingestion  of  food,   associated   with 
pain.  111 


Ingestion  of  food,  effect  of,  on  pain, 

116 
intestinal  pain  after,  472,  473 
Inguinal  hernia,  case  of,  cited,  374 
colicky  pain  in,  referred  to  lower 

quadrant  of  abdomen,  375 
pain  in,  374 

pressure  on,   effect  of,  374 
Inherited     predisposition     to     neu- 
ralgia,  143 
Inhibition,  of  pain  sensation,  62 

of  perception,  63 
Intellect,  mental  activity  of,  13 
power  of,  to  reproduce  pain  by 

memory,  13 
Intensity  of  pain,  114 

algometers     in     measuring,     130, 

131 
amount  of  morpliin  necessaiy  as 

indication  of,  120,  125 
ai^pearance  of  patient  indicating, 

120,  125 
as  a  stimulus,  114 
blood  pressure  elevation  indicat- 
ing, 120 
circulation  indicating,  134 
complaints  of  patient  indicating, 

120,  123 
depending  factors  of,  114 
dilatation     of    pupil    indicating, 

120,  125 
facial  expression  indicating,  127 
gestures  indicating,  128 
in  spinal  cord  lesions,  216 
irritability  of  nerves  a  factor  in, 

115 
loss    of    equilibrium    indicating, 

134 
mechanical  factors  in  measuring, 

120,  129 
minima    of,    table    representing, 

130 
motion  indicating,  128 
motor  reflexes  indicating,  120,  122 
nerve  fibers  involved  a  factor  of, 

115 


INDEX 


891 


Intensity  of  pain,  patient's  descrip- 
tion indicating,  120,  128 
respiratoi-y  system  indicating,  134 
sensitiveness  of  patient  a  factor 

of,  115 
trophic   changes   indicating,   134, 

135 
vasomotor  signs  of,  120.  124 
Von   Frey's  hairs  in   measuring, 
130,  131 
Intercostal  neuralgia,  147,  164 
differentiation     between     cardiac 

disease  and,  781 
distinguished  from  herpes  zoster, 

165 
distinguished  from  pleurisy,  165 
epidemic  of,  143 
location  of  pain   and  tenderness 

in;  72 
posture  in,   127 
respiration  in,  127 
Intercostal  neuritis,  791 
Interference  with  areas  of  pain  per- 
ception, 64 
Intermenstrual  pain,  735 
Intermittent    claudication,    descrip- 
tion of,  251,  252 
Intestinal  adhesions,  ease  of,  cited, 

370 
Intestinal  atony,  effect  of  constipa- 
tion in,  118 
Intestinal  diseases,  pains  due  to,  401 
Intestinal   obstruction,    acute,    492, 
493 
associated  symptoms  with,  494 
cause  of,  493 
chronic,   493,   494 
Intestinal    pain,    associated    symp- 
toms with,  474 
colonic,  500 
diagnostic  points  in,  location  of, 

469 
diarrhea  with,  475 
due  to  colonic  involvement,  500 
due    to     pressure     on     adjacent 
nerves,  468 


Intestinal    pain,    due    to    purpura, 

402 
due  to  traction  of  the  mesenterj-, 

465 
due  to  tuberculous  intestinal  le- 
sions and  leukemia,  469 
duration   of,  473 
etiology  of,  463 
general  considerations  of,  463 
glandular  enlargement  with,  476 
history  of,  473 
ingestion    of    food    followed    by, 

472,   473 
lesions  causing,  476 
localization  of,  467 
location  of,  469 
muscular  acti\aty  causing,  468 
of  the  anus,  509 
of  the  rectum,  505 
onset  of,  indications  from  manner 

of,   471 
peristalsis  stimulation  of,  by  food 

in,  472 
position  of  patient  in,  472 
rectal,  505 
referred,  468 
reflected,  467 
result  of,  473 

shock  and  collapse  with,  475 
tenderness  with,  deep,  474 

superficial,  474 
tension  as  stimulus  for,  465 
tumor  formation  with  peristalsis 

in,  472 
types  of,  470 
vomiting  with,  474 
Intestinal    secretion,    disorders    of, 

480 
Intestinal  ulcer,  action  of  food  in, 

488 
intervals   of  freedom  from   pain 

in,  487 
location  of,  487 
relief  of  pain  of,  488 
severity  of  pain  in,  488 
tuberculous,  488 


892 


INDEX 


Intestinal  ulceration,  catarrhal,  489 
syphilitic,  489 
typhoidal,  488 
Intestines,  back  pains  due  to,  302 
degi'ee  of  sensitiveness  of,  to  pain 

stimuli,  388 
epigastric  pain  from  lesions  of, 

397 
functional  disturbances  of,  477 
law    of   contrary    innervation    in 

(Meltzer),  387,  388 
lesions  of,  causing  pain,  476 
mesentei-y  of,  463 
motor  disturbances  of,  478 
new  gi-owths  of,  499 
normal  stimuli  reactions  of,  387 
pain  in,  due  to  acute  indigestion, 
402 
due  to  gall-stones,  402 
due  to  hernia,  402 
due  to  obstruction,  401 
due  to  poisoning,  402 
due  to  renal  calculus,  402 
due  to  uremia,  402 
production  of  pain  in,  464 
secretory  disturbances  of,  477 
spasm  of,  479,  480 
stimulus  for  pain  production  in, 

463,  464,  465 
ulcers  of,  487 
Intra-articular    hip    joint    abscess, 
description  of,  244 
diagnosis  of,  244 
nocturnal  pains  of,  244 
treatment  of,  244,  245 
Intracranial  head  pains,  causes  of, 

269 
Intradural  suppuration,  338 
Intraneural  causes  of  neuralgia,  142 
Intraparenchymatous   pain,    disten- 
tion of  liver  causing,  551 
Intrinsic    factors    modifying    pain 

production,  116 
Introitus   narium,   pain   caused  by, 

342 
Intussusception,  496,  497,  498 


lodids,  uses  of,  119 
Iridectomy,  329 
Iridocyclitis,  326 
Iris,  pain  in  the,  325,  326 
Iritis,  forms  of,  326 

light  as  a  cause  of  pain  in,  323 

myopic,  327 

source  of  pain  in,  318 

sudden  exacerbation   of  pain  in, 
326 

treatment  of,  326 
Ischemia,   anesthesia  by,   66 
Ischiorectal  abscess,  509 


Jacksonian  epilepsy,  184 
Jacksonian  fits,  183 
Jacksonian  spasms,  184 
Joint  pains,  classification  of,  234 
infections  causes  of,  238 
inflammatoiy,  diagnosis  of,  239 
intensity  of,  236 
nonseptic,  diagnosis  of,  239 
of  the  hip,  241,  242 
organic,  234 
radiation  of,  236 
redness  as  a  symptom  of,  238 
rheumatic  inflammation  in,  diag- 
nosis of,  239 
septic,  diagnosis  of,  239 
swelling   as   a   symptom   of,   238 
symptoms  of,  236,  237,  238 
tenderness  as  a  symptom  of,  237, 

238 
traumatic  causes  of,  238 
verification  of  a  patient's  descrip- 
tion   of,    by    manipulation, 
237,  238 
by  palpation,  237 
by  therai^eutie  test,  238 
Joints,  as  cause  of  pain  from  mo- 
tion, 117 
growing,   241 

hypersensitive,  cessation  of  func- 
tion of,  causes  of,  237 


INDEX 


893 


Joints,  order  of  frequency  of  in- 
volvement of  (Eisendrath), 
239 


K 


Kala-azar,  602 

Keratitis,  punctate  superficial  den- 
dritic, 325 

stellate,  325 

superficial,   severity   of   pain   in, 
323 

ulcerating,  325 
Kidney,     anatomical     position     of, 
604,   608 

back  pains  referred  from,  302 

congestion    in    inflammation    of, 
630 

cystic  disease  of,  645 

displaced,  620 

epigastric  pains  from  lesions  of, 
397 

general  considerations  of,  604 

hydatid  disease  of,  646 

hypernephroma  of,  646 

hypertension  of,  607 

insensibility    of    parenchyma   of, 
606 

location  of,  608 

lumbar  plexus,  relation  with,  606 

movable,  620 

nerve  supply  of,  604 

new  growths  of,  644 

character  of  pain  in,  645 
etiology  of,  644 
varieties  of,  645 

parenchymatous  infection  of,  649 

polycystic  disease  of,  645 

rotation  of,  from  liver  displace- 
ment, 559 

sarcoma  of,  646 

tenderness  in,  615 

most  marked  points  of,  616 

tuberculosis  of,   642 

wandering,  pain  of,  607 


Kidney  area,  edema  in,  presence  of, 

618 
Kidney  disease,  absence  of  pain  in, 
CIS 
differential  diagnosis  6f,  610,  619, 
620,  621,  649,  669 
of  hydronephrosis  in,  656 
of  movable  kidney,  627 
of   perinephritic   abscess,    639, 

640,   641 
of    pyelitis     or    pyonephrosis, 

650 
of  renal  calculus,  668 
of  renal  infarction,  628 
of  renal  tuberculosis,  644 
of  tumor,  646 
hydronephrosis  in,  650  ' 

pain  in  diagnosis  of,  619 
Kidney   inflammation,    acute.      See 
Nephritis, 
chronic,  632 
congestion  in,  629 
Kidney  pain,  absence  of,  in  kidney 
lesions,  618 
character  of,   607 
differential     diagnosis     of,     620, 
621 
of  renal  calculus,  650 
differential  points,  610 
duration  of,  618 
etiology  of,  605 
from  bladder  tumors,  689 
local,   607 
localization  of,  607 
motion  of  patient  in  relation  to 

production  of,  CIS 
position  of  patient  in,  617 
production  of,  factors  influencing, 

617 
psoas  muscle  contraction  causing, 

616 
referred,  608 

nerves  involved  in,  612 
reflected,   614 
subjective,  607 
symptoms  associated  with,  618 


894 


INDEX 


Kidney  pain,  tension,  intracapsular, 
606 
on  renal  capsule  causing,  605, 
606 

Kidney  rupture,  641 

Kidney  stones.    See  Renal  calculus. 

Kidney  tumor,  646 

Killian   operation,  resection  of  su- 
praorbital nerve  in,  350 

Knee,  radiated  to,  pain  from  flat- 
foot,  305 

Knee  pains  propagated  through  ob- 
turator nerve,  241 


Labor,  absence  of  pain  in,  739 

first  stage  of  pains  in,  739 

pain  in,  738 

referred  pains  of,  740 
Labyrinth,  diseases  of,  340 
Lacrimation,  317 
Lactation  mastitis,  258 
Laryngeal  crises  of  tabes  dorsalis, 

359 
Larynx,  acute  affections  of,  357 

anesthesia    of    entrance    to,    for 
dysphagia,  358 

carcinoma  of,  358 

chronic  processes  of,  358 

inflammation  of,  357 

neuralgia   of,    359 

pain  in  acute  affections  of,  357 
diseases  of,  356 

pus  formations  in,  357 

referred  pain  of,  357 

sensory  nerves  of,   356 

tuberculous  ulcers  of,  358 
Laws,  Hilton's,  220 

law  of  contrary  innervation,  223 
Lead  as  cause  of  neuralgia,  142 
Lead  colic,  402,  484 
Leontiasis  ossea,  233 
Leptomeningitis,    diffei'ential    diag- 
nosis of,  196 


Leptomeningitis  purulenta,  differen- 
tial diagnosis  of,  195,  196 
headache  and  other  symptoms  of, 
180,  190,  191 
Leptomeningitis  serosa,  differential 

diagnosis  of,  195,  196 
Leukemia,  back  pain  of,  299 
bone  pains  of,  231,  232,  233 
myelogenous,  602 
symjitoms  of,  181 
Limbs,   localizing  center  for  pain, 
304 
lower,  flat-foot,  305 

generalized  pain  in,  305 
heel  pains,  306 
hip  joint  affections,  305 
pain  from  circulatory  changes, 
305 
upper,  pain  in,  304 
shoulder  pains,  304 
Lingual  nerve,  351 
Lipomatosis,  multiple,  224 
Lips,  pain  in,  418 
Liver,  abscesses  of,  553 
adhesions,   553 

atrophy  of,  acute  yellow,  561 
back  pains  refeired  from,  302 
cirrhosis  of,  552,  554,  556 

acute  chronic,  561 
congestion  of,  551 

due  to  acute  inflammatory  le- 
sions, 553 
cysts  of,  555 
displacement  of,  558 
distention  of,  551 
epigastric  pain  from,  lesions  of, 

397 
essential  diseases  of,  561 
examination  for  pain  in,  543 
growths  of  slow  development  in, 

555 
inflammation   of  the  capsule   of, 

557 
malignant  disease  of,  556 
nerve  supply  to,  540,  543 
new  gi'owths  of,  554 


INDEX 


895 


Liver,  painful  disordefs  of,  540 
pain   in,  545 

secondaiy  growths  of,  555 
secondary  involvement  of,  556 
sensitive  area  in,  541 
sensitiveness  to  pain  of,  produc- 
ing stimuli,  542 
syphilis  of,  556 
tropical  abscess  of,  554 
vagus  in  innervation  of,  541 
Liver  disease,  in  relation   to  other 

disorders,  548 
pain  in  right  shoulder  in,  542 
palpation  in,   544 
percussion   in,   544 
sensibility  examination  in,  545 
symptoms  in  diagnosis  of,  543 
tenderness  as  a  symptom  of,  543 
elicitation  of,  544 
Liver  pain,  character  of,  545 
disturbance    of    liver    substance 

proper,  550 
extraparenchymatous,    canses   of, 

550 
ingestion   of  food   and   diTink  in 

relation  to,  545 
intraparenchymatous,    causes    of, 

551 
movement  of  the  body  producing, 

547 
neuralgia,  550 
position  of  the  body  in  relation 

to,  547 
time  of  appearance  of,  549 
with  pregnancy,  548 
Localization   of  pain,   accuracy  of, 

decreased  by  hyperalgesia,  70 
deei'eased  by  hyperesthesia,  70 
indefinite  area  of,  48 
motion  in,  48 
muscles  in,  48 
nervi  nervorum  in,  48 
peripheral     sensory     nerves     in, 

51 
touch  sense  in,  48 
Localized  anemia,  62 


Locomotor  apparatus,  pain  of,  diur- 
nal, 110 
Locomotor  ataxia,  epigastric  pains 
from,  397 
projection  pain  in,  103 
Lorenz   plaster  hose  for  hip   joint 

abscess,  244 
Lower  animals,  sensation  in,  1,  3,  4 
Luetic  ulcers,  pain  of,  355 
syphilitic  process   of,  355 
Lumbago,   221,   222,   296 

distinguished   from  neurasthenia, 
297 
Lumbar  cord  neuralgia.    See  sacral. 
Lumbar     plexus,     distribution     of 

nerves  from,  52 
Lumbar   segments,    distribution   of, 

diagram  of,  57 
Lumbosacral  lesions,  209 
Lung  pain,  etiology  of,  790 

referred,  distribution  of,  790 
Lungs,   areas   of  pain   of,   in   rela- 
tion to  location  of  lesion,  792 
back  pains  due  to  affections  of, 
300 
Lupus  and  lues,  333 
Lymphadenoma  ossium,  233 
Lymphangitis,  442 

with  gastric  ulcer,  458 
Lymphatic  headache,  290 


M 


Malaria,    spleen,    enlargement    of, 

from,    600 
Mammary  gland,  257 

pain  produced  by  changes  in,  259 
Marking  code  for  recording   pain, 

136 
Massage,   effect   of,   for   neuralgia, 

161 
Mastitis,  259 
lactation,  258 
pyogenic,  258 
stagnation,  258 


896 


INDEX 


Mastoid,    significance   of   suppura- 
tion of,  337 
Mastoid  process,  abscess  in,  336 
Maximum    tenderness    areas,    cord 

zones,  and  diagram  of,  59 
Meatus,  external  lesions  of,  335 
Mechanical  changes,  causative  fac- 
tors  of  pain,  25 
Mechanical   factors   for  measuring 

pain,  129,  130,  131 
Mechanical  irritation,  due  to  pres- 
sure or  contraction,  25 
Mediastinum,  pain  of,  802 
Medulla,  tumors  of,  186 
Memorj',  13 

Memoiy  centei-s,  for  pain,  24,  25 
subjective   pains   drawn    from, 
75 
Meningeal  apoplexy,  symptoms  of, 

209 
Meningeal    changes,    as    cause    of 
headache,  functional,  269 
organic,  271 
Meninges,  sj^philis  of,  213 
Meningitis,    acute,    as   a   cause   of 
headache,  271 
spinal,   212 
cerebrospinal,  212 
diagnosed  from  indurative  head- 
ache, 267 
rigidity  in,  127 

tuberculous.       See     Tuberculous 
meningitis. 
Menstrual  pain,  conclusions  in  re- 
gard to,  734 
intermenstrual,  735 
time  of  occurrence  of,  735 
Menstruation,    back   pains   due   to, 
303 
contraction  of  uterine  muscles  in 

nonnal,  729 
pain  due  to,  718 
painful,  728 

physical  factor  of  pain  in,  116 
Mental  activity,  13 
Mental  disturbances  from  pain,  134 


Mental  resultants,  14 
Mental  states,  14 

influence  of,  on  mental  processes 

of  the  body,  124 
pain  and,  30,  31 
relation  of  pain  and  pleasure  to, 
15,  30,  31 
Mereuiy,  as  cause  of  neuralgia,  142 

uses  of,  119 
Mesenteric    arteries,    embolism    of, 
253,  254 
thrombosis  of,  253,  254 
Mesenteric  glands,  enlargement  of, 
in  tuberculosis,  261 
pain   in,   261 
Mesenteiy,  factor  of  pain  produc- 
tion in  hernia,  372 
traction  on,  cause  of  pain  in  vis- 
cera, 390 
Metabolism  as  cause  of  head  pains, 

268 
Metaphysical  consideration  of  pain, 

20,  21,  22 
Metastases,  gastric  ulcer  due  to,  458 
Metastatic  growths,  555 
Metatarsalgia,  306 
Middle-ear,  catarrh  of,  339 

complications  of  disease  of,  337 
disease  of,  335 
pus  in,  337,  338 
Migraine,  189 

associated  symptoms  of,  287 
diagnosed  from  indurative  head- 
ache, 267 
differential  diagnosis  of,  196,  197, 

198 
due  to  contraction  of  peripheral 

arteries,  288 
due    to    diminished    secretion    of 

thyroidin,  289 
due  to  habit,  289 
due     to     increased     intracranial 

pressure,  287,  288 
due  to  malaria,  289 
due  to  stenosis  of  the  foramen 
of  Monroe,  288 


INDEX 


897 


Migraine,  due  to  syphilis,  289 
eye  pain  from,  320 
hereditary,  286 
hysterical,   289 

localization  of  headache  in,   192 
ophthalmoplegic,  321 
premonitory  symptoms  of,  287 
reflex,  286 
scintillating  scotoma  as  symptom 

of,  287 
throbbing  pain  of,  287 
Minima   of  sensation,   table  repre- 
senting, 130 
Misplaced  \dscera,  neuralgia  from, 

142 
Misreference  of  pain  phenomena,  94 
Molecular  disturbance  as  cause  of 

neuralgia,  142 
Monomania  pains,  80 
Morphin,  effects  of,  119 

on  blood  pressure  elevation,  121 
in  colic,  125 

measuring  intensity  of  pain  by, 
120,  125 
Morton's  neuralgia,  169 
Motion,  bone  cause  of  pain  from, 
117 
cell  areas  of,  10 
intensity   of    pain   indicated    by, 

128 
joints  as  cause  of  pain  from,  117 
localization  of  pain  by,  48 
muscles  as  cause  of  pain  from, 

117 
physical  factor  of  jDain,  116 
reflex,  2,  3 
Motor  fibers,  coui-se  of,  174 
Motor    manifestation    of    pain    in 

lower  animals,  3 
Motor  reflexes,  in  measuring  inten- 
sity of  pain,  120,  122,  123 
protective  tendency  of,  122,  123 
Motor  region,  effect  of  removal  of, 
7,  8 
focal  symptoms  of,  183 
location   of,   173 


Movable  kidney,  anatomical  consid- 
erations of,  620 
associated  sjTni^toms  of,  625 
character  of  pain  in,   624 
constipation  with,  626 
differential  diagnosis  of,   627 
digestive  disturbances  with,  625 
lesions  with,  626 
location  of  pain  in,  623 
paroxysmal  pains  in,  624 
pathology   of,   622 
tenderness  with,  626 
tumor  with,  625 
urinary  changes  in,  625 
Multiple  sclerosis,  differential  diag- 
nosis of,  197,  213 
symptoms  of,  213 
Mumps,  423 

Muscle  fiber,  activity  of,  468 
Muscles,  as  seat  of  head  pains,  265 
causative  factor  of  back  pain,  296 
causes  ©f  pain  in  use  of,  117 
inflammation  of,  219 
in  localization  of  pain,  48 
involuntary,  colics  of,  222 
motor  nerves  of,  50 
nei^e  flbei-s  of,  48,  50 
pain  in,  218 
pain  producing  diseases  of,  218, 

219 
protective  tendency  of,  123 
sensation  in,  48 
sensoiy  nerves  of,  50 
underlying,  rigidity  of,  associated 

with  tenderness,  72 
voluntary,  diseases  of,  219 
induration  of,  222 
myalgia  of,  221 
myositis  of,  219 
myositis  fibrosa  of,  221 
myositis  haemorrhagica  of,  221 
myositis  ossificans  of,  221 
polymyositis  of,  acute,  220 
DIuseular  changes   from   neuralgia, 

146 
Muscular  pain,  abdominal,  361 


898 


INDEX 


Muscular  rigidity,   with   abdominal 

pain,  413 
Muscular    spasm,    with    abdominal 

pains,   413 
Muscular  tissues,  pain  in,  218 
Myalgia,  221 
abdominal,  362 
character  of  pains  of,  222 
of  back,  due  to  fatigue,  298 
due  to  sprain,  298 
due  to  toxemia,  297 
Myelitis,  212 

Myelogenous  leukemia,  602 
Myeloma,  bones,  233 
Myocarditis,  788 

Myositis,    description    of    pain    of, 
218 
forms  of,  220 
Myositis  fibrosa,  221 
Myositis  ha;morrhagica,  221 
Myositis  ossificans,  221 
Myringitis  bulbosa,  335 


N 


Nails,  absence  of  pain  in,  113 
Nasal  septum  abscesses,  pain  caused 

by,  342 
Nasal  stenosis,  headaches  caused  by, 

342 
Nasal  tumoi-s,  headaches  as  symp- 
tom of,  347 
Naunyn's  sign,  565 
Nausea,  protective  tendency  of,  123 
Neck,  localizing  center  for  pain,  312 
Neck  pains,  causes  of,  312 
Nephralgia,  hematuric,  629 
Nephritis,  associated  symptoms  of, 
633,  636 
character  of  pain  in,  632 
Head's  zones  in,  631 

sensory   disturbances  in,   illus- 
trative cases,  633,  635 
hyperalgesia,  area  of,  636,  637 
pain  in,  631 
referred  pain  in,  632 


Nervo  apparatus,  5 

for  receiving  and  conducting  pain, 
28 
Nerve  fibers,  conveying  deej)  sensi- 
bility, 37,  38 

convej'ing   superficial    sensibility, 
37 

extent    and   number   involved   as 
factor  of  pain  intensity,  115 

gray  matter  cells,  arising  in,  42 

of  muscles  and  skin,  48,  50 

posterior  cornua  entering,  41,  42 
Nerve  force,  5 

regenerated  by  adrenalin,  102 
Nerve  supply,  of  the  kidneys,  604 

of  the  pancreas,  481 

of  the  I'ectum,  506 

of  the  spleen,  593 

to  the  bladder,  672 

to  Fallopian  tubes,  707 

to  female  genitalia,  705,  706,  712 

to  the  heart,  774 

to  liver,  540,  543 

to  the  ovaries,  707,  713 

to  the  pleura,  769 

to  the  stomach,  428 

to  the  testicles,  698 

to  the  ureter,  670 

to  the  uterus,  707,  713,  724 

to  the  vagina,  755 
Nerve  tenninals,  affections  of,  140 
Nerve  trunks,  affections  of,  140 
Nerves,  as  seat  of  head  pains,  268 

destruction  of  endings  of,  364 

involved  in  referred  kidney  pain, 
612 

iiTitability  of,  115 

of  nose,  341 

of  pain,  36 

pain  in  diseases  of,  140 

sensoi-y,  of  the  larynx,  356 
of  the  pharynx,  351 
Nervi  nervorum,  in  localization  of 

pain,  48 
Nervous  system,  autonomic  sympa- 
thetic, 12 


INDEX 


899 


Nervous  system,  central,  172 

evolution  of,  31,  32 

importance  of,  79 

in  lower  animals,  2,   3,  4 

localization  of  pains  due  to  dis- 
eases of,  175 

of  the  ureter,  670 
Nervus  nasalis  anterior,  course  of, 

341 
Nei'vus  nasopalatinnm,  scarpi,  341 
Neuralgia,    anesthesia    dolorosa   in, 
144 

area  of  pain  of,  144 

as  cause  of  head  jDains,  268 

brachial,  147,  150 

causes  of,  140,  141,  142,  143,  144 

character  of  pains  of,  144 

circumflex,  147,  164 

consideration   of,   as    a   separate 
entity,  141 

consideration  of  tenn,  158 

diagnosis  of,  147 

differential  diagnosis  of,  general, 
106,  147 

differentiated  from   muscular  le- 
sions, 147 
neuritis,  140,  159 
tabes,  149 

distant  points  in,  145 

duration  of,  146 

effects  of,  146 
on  heart,  146 

epidemic   of,   intercostal,   143 

etiology  of,  142 

exciting  causes  of,  142 

extraneural  causes  of,   142 

galvanic  current  for,  145 

general  discussion  of,  141 

infection,  as  cause  of,  143 

inherited  predisposition  to,  143 

in  influenza,  141 

in  senility,  141 

intercostal,  147,  164 

intraneural  causes  of,  142 

laryngeal,  359 

local  points  in,  144,  145 


Neuralgia,  massage  for,  161 
Morton's,  169 

muscular  changes  from,  146 
nose  as  cause  of,  149 
of  abdominal  organs,  409 
of  abdominal  wall,  symptoms  of, 

361,  362 
of  cheeks,  418,  419 
of  cortex,  causing  headaches,  278 
of  eyelid,  fifth  nerve,  320 

diagnosis  of,  321 
of  lips,  418 
of  liver,  550 
of  lumbar  cord,  169 
of  ovary,  749 
of  pharynx,  356 
of  stomach  nei'ves,  461,  462 
of  the  uterus,  726 
pathology  of,   141 
peroneal,  147 
piercing    pain    of,    differentiated 

from  bone  pains,  228 
plantar,    169 

predisposing  factors  to,  143 
predisposition  to,  by  alcohol,  143 

by  drugs,  143 

by  excessive  sexual  indulgence, 

•    143 

by  tobacco,  143 

from  senility,  143 
projected  pain  causing,  144 
referred  pain   causing,  144,  149, 
158 

diffei'entiated  from,  102 
reflex  irritations  causing,  143 
relieved  by  endonasal  operation, 

350 
sacral,  169 

sinus  suppuration  producing,  345 
skin  as  the  seat  of,  265 
supraorbital,  143 
sympathetic  pain  causing,  144 
symptoms,   143 
syphilitic,  147 
teeth  affected  by,  148 
thoracic,  760,  763 


900 


INDEX 


Neuralgia,  toxic  materials  causing, 

141,  142 
traumatism  as  cause  of,  143 
trigeminal,  146,   147,  148,  149 
trophic  changes  in,  146 
types   of,   according   to   localiza- 
tion, 147 
sciatic,  147,  166 
Valleix's  points,  144,  145 
vasomotor  changes  in,  145 
visceral,  147 
Neuralgic   pains  from   spinal   cord 

tumors,  211 
Neurasthenia,    abdominal    pain    in, 

409,   410 
differential   diagnosis  of,  196 
differentiated  from  caries  of  the 

vertebral  canal,  210 
lumbago,   297 
due  to  long  continued  lesion   of 

female  genitalia,  712 
headache    and    other    symptoms, 

189,  190 
pains  of,  215. 

predisposing  to  neuralgia,  143 
sense  of  pressure  in  head  with, 

264 
symptoms  of,  216 
Neurasthenics,  diurnal  pain  of,  110 
Neuritis,   abdominal,   of   intercostal 

nerves,   362 
as  cause  of  head  pains,  268 
brachial  neuralgia  in,  150 
causes  of,  140,  141 
differential  diagnosis  of,  147 
distinguished  from  neuralgia,  140, 

141,  142,  159 
localization  of,  153 
of  the  esophagus,  424 
symptoms  of,  143 
thoracic,   762 
Neuropathic    conditions,    effect    of 

constipation  in,  118 
Neurosis,  effect  of  ingestion  of  food 

in,  116 
occupation,  cause  of,  30 


Neurotic      ostalgias,     distinguished 

from  bone  pains,  233 
Neutral  sensations,  14 
New  growths,  abdominal,  362 
causing  bone  pains,  230 
intestinal,  499 
of  the  gall-bladder,  571 
of  the  liver,  554 
of  the  rectum,  507 
of  the  stomach,  455 
of  the  uterus,  743 
Nicotin  as  cause  of  neuralgia,   142 
Nociceptors,   29 
Nocturnal  ostalgia,  228 
Nocturnal  pains,  110,  244 
Nocuous  ceptors,  29 
Nose,  adenoid  vegetation  of,  343 
diseases  producing  pain  in,  342 
empyema  of  the  smuses,  343 
headaches       from      obstructed 
sinuses,  345 
from  tumors  of,  347 
from    sphenopalatine    diseases 
of,  345 
hypertrophy  of  middle  turbinate 

causing  headaches,  349 
in  neuralgia,  149 
local    pains    in    cavities    of    the 

sinuses  of,  344 
neuralgia   of,    from   suppuration 

of  the  sinuses,  345 
obstructed  sinuses  in,  345 
pain  in  diseases  of,  341 
reflex  neuroses  of,  344 
sensory  nerves  of,  341 
tumors  of,  347 
Numbness.     See  Paresthesia. 


0 


Objective  pain,  82 
abdominal,  360 
central,  82 
origin  for,  82 
thalamic,  83 
peripheral,  83,  89 


INDEX 


901 


Obstruction,  appendicial,  517 

due  to  hernia,  499 

in   the  gall-ducts,   572 

of  intestines,  492 
Occupation  neuroses,  80,  81 
Ocular  headaches,  282 
Omental  hernias,  373 
Oophoritis,    remission    of    constant 

pain  in,  109 
Ophthalmoplegic  migraine,  320 
Optic  nerve,  pain  in,  328 
Optic  thalamus,  origin  for  central 

objective  pains,  82 
Organ,  structures  of  an,  84 
Organic  disturbances  causing  head- 
aches, 277 
Organs  of  sense,  5,  11 

of  sense  perception,  11 
Ostalgia,  nocturnal,  228 
Ostalgias.     See  Bone  pains. 
Osteitis   deformans,   233 
Osteomalacia,  232 

back  pains  of,  300 

description  of,  232 

distinguished     from     spondylitis, 
232 

symptoms  of,  227 
Osteomyelitis,  231 

acute,  231 

chronic,  231 

of  the  thorax,  764 

symptoms  of,  227,  228,  231,  236 
Otalgia  excarie  dentium,  340 
Othematoma,   332 
Otitis  externa  diffusa,  334 
Otitis  media,  acute,  335 

differential    diagnosis    of,    195, 

196 
forms  of,  336 
Otosclerosis,  339 
Ovarian  diseases,   transferred  pain 

in,  107 
Ovarian  dysmenorrhea,  734 
Ovarian  pain,  causes  of,  748 

characteristics  of,  748 

local  point  of,  748 


Ovaries,  abscess  of,  751 
adhesions  of,  752,  754 
back  pains,  referred  from,  303 
cysts  of,  753 
displacement   of,   749 
hernia  of,  749 
hyperemia  of,  749 
nerve  supply  to,  707,  713 
neuralgia  of,   749 
pain   in,   747 

relation  of,  to  parotids,  752 
tuberculosis  of,  752 


Pachymeningitis  externa,  337 
Pachymeningitis   haemorrhagica   in- 
terna,   differential    diagnosis 
of,  198 
etiology  of,  179 

headache  and  other  symptoms  of, 
179,   180,  190,   191 
Pachymeningitis  interna  as  a  cause 

of  headache,  271 
Pachymeningitis  spinalis  hyper- 

trophica,   212 
Pain,   character  of,   108,   109 
classification  of,  74,  89 
conditions  associated  with,  132 
constant,  109 

definitions  of,  13,  18,  19,  20 
description   of,   by   patient,    108, 

109 
orientation  of  cause  of,  262 
Pain  filaments,  unequal  distribution 

of,   48 
Pallor,   indicating   shock,    124,   125 
indicating  intensity  of  pain,  124 
Pancreas,      back     pains,     referred 
from,  303 
cancer  of,  579,  591 
character  of  pain  in,  485 
cystic  diseases  of,  491 
diagnostic  importance  of  pain  in, 

484 
diseases  of,  causing  pain,  587 


902 


INDEX 


Pancreas,  epigastric  pains  fx-om  le- 
sions of,  397 
general  considerations  of,  480 
location  of  pain  in,  485 
nen'e  supply  of,  481 
pain  in,  580,  587 
peritoneal  covering  of,  stretching 

of,  483 
position  of  patient  in  diseases  of, 

487 
reaction  to  pain  stimuli  in,  484 
relationship   of,    to    other   parts, 

484 
structure  of,  482 
tenderness  in  lesions  of,  486 
Pancreatic  calculi,  489 
Pancreatic  lesions,  possibility  of,  in 
apparent  peritonitis  or  intes- 
tinal obstruction,  485 
Pancreatitis,     acute,     distinguished 
from  gastric  ulcer,  451 
hemorrhagic,  487 
symptoms  of,  488 
chronic,  489 
Fitz's  rule  for,  488 
subacute,  488 

associated  symptoms  of,  489 
tenderness  in,  488 
tenderness  in,  487 
Panophthalmitis,  pain  of,  330 
Papilledema,     associated    with    tu- 
mors, 183 
Papillitis  of  the  tongue,  422 
Paracentesis,  336 
Paralysis,  areas  of,  59 

from  tumors,  183,  184,  185 
Paraparesis,  184 
Paraphasia  from  tumors  of  frontal 

lobe,  184 
Parasites  of  the  brain,  187 
Parenchymatous    infection    of    the 

kidney,  649 
Parenchymatous  pains,  83,  84,  140 
causes  of,  84 

chemical     initations     producing, 
88 


Parenchymatous   pains,  due  to  in- 
flammation of  the  viscera,  86 

inflaunnatory,  84 

in  glandular  organs,  87 

radiation  of,  86 

thermic  irritations  producing,  88 

torsion  producing,  88 

traction  producing,  88 
Paresis,  causing  anesthesia,  65 

differential  diagnosis  of,   197 
Paresthesia,  simulated  pain  in,  61, 73 
Paresthesias,  183 
Parietal  lobe,  tumors  of,  184 
Parotid  gland  as  cause  of  pain,  423 
Parotids,  relation  of  ovaries  to,  752 
Paroxysmal  pains,  109 

crises  in,  109 
Pedicle,  toi-sion  of,  399 
Pedunculi  cerebri,  tumors  of,  185 
Pelvic  adhesions,  cases  cited,  370 

pain  of,  when  present,  370 
Pelvic  diseases,  diagnosis  of,  722 
importance  of  considering  the 
l^atient  in,  724 

discharge  in,  723 

epigastric  pains  from,  398 

history  of  case  of,  722 

menstrual  flow  in,  character  of, 
723 

pain  production  in,  predisposing 
factors  to,  723 
Pelvic    pain,     diagnosis    of,    from 
hysterical,   709,   710,   711 

examination,     bimanual    vaginal, 
importance  of,  in,  722 

functional   acts,   relation  to,   717 

motion  causing,  718 

on  coitus,  717 

on  menstruation,  718 

position  assumed  by  patient  suf- 
fering from,  716 

position,  change  of,  causing,  718 

symptoms  of,  709 

tenderness  areas  of,  720 

tenderness  due  to,  719 

varieties  of,  712,  715 


INDEX 


903 


Pemphigi  of  the  mucosa,  356 
Penis,  pain  in,   703 

referred  pain  in,  703 
Perception,  inhibition  of,  63 
centers  for,  30 
degrees  of,  61 
drugs,  effect  of,  on,  63 
idiocy,  effect  of,  on,  62 
inhibition  of,  62,  63 
in  thalamic  lesions,  199,  200,  201, 

202 
loss     of,     by     interference     with 
areas  of,  64 
in  anesthesia,  63 
of  pain,  analgesia  of,  61 
perversion  of,  61 
psychosis,  effect  of,  on,  62 
single  impression  of,  at  one  time, 

71 
toxemia,  effects  of,  on,  62 
Perceptive     apparatus     for     pain, 

30 
Perceptive  centers  of  pleasure  and 

pain,  21,  22,  23 
Perforating  ulcers,  419 
Perforation,  ^n  typhoid,  402,  403 

of  a  viscus,   effect  of,  416 
Perianal  abscess,  512 
Pericardium,  disease  of,  788 
Perichondritis,  332,  333 
Pericystitis,  689 
Perigastric  adhesions,  459 

localization  of,  in  the  abdominal 

wall  by  palpation,  460 
symptoms  of,  461 
Perihepatitis,  557 

adhesions  following,  560 
Perimysium,    sensitiveness   to    pain 

of,  113 
Perinephritie     abscess,     differential 

diagnosis  of,  639,  640,  641 
Perinephritis,  associated  symptoms 
in,  640 
character  of  pain  in,  637 
location  of  pain  in,  638 
posture  in,    640 


Perinephritis,  referred  pain  in,  638 

tenderness  in,  638 
Periosteal  lesions,  229 
Periosteum,   condition   of,   in   pain 
from  motion,  117 

dull  aching  character  of  pain  of, 
228 

sensitiveness  to  pain  of,  113 
Peripheral  causes  of  anesthesia,  65 
Peripheral    distribution,    of    nerve 
fibers,  interpretation  of  pain 
as  coming  from,  393 

of  sensory  fibers,  50,  51 
Peripheral    nerves,    section    of,    in 

neuralgia,  65 
Peripheral  pains,  associated,  90 

causes  of,  83 

character  of,  108,  109 

extrinsic  causes  of,  83 

functional   causes  of,  84 

intrinsic  causes  of,  83 

objective,  83,  89 

organic  causes  of,  83 

persistency  of,  109 

projected,  103 

propagation  of,  89 

referred,  95 

reflected,    104 

sympathetic,  102,  103 

time  of,  110 

transferred,  106 
Periphlebitis   of  lateral   sinus,  337 
Perisinus  abscess,  338 
Perisplenitis,  600 

causes  of,  601 

degrees  of  pain  in,  594,  600 

friction  sounds  in,  601 
Peristalsis,  relation  between  gastric 
and  intestinal,  486 

relation  to  pain  production,  499 
Peritoneal   adhesions,  general   pain 

of,  when  present,  371 
Peritoneal    irritation    with    hernia, 

373 
Peritoneum,    absence   of   pain   per- 
ception in,  363 


904 


INDEX 


Peritoneum,  adhesions  of,  367,  368 
diseases   of,    producing   pain    in, 

364 
hemon'hage  of,  367 
inflammations  of,  364 
layers  of,  363 

painful    impulses    of,    seated   in 
subperitoneal  layer,  362,  363 
sensitiveness  to  pain  of,  113 
tumors  of,  367 
Peritonitis,     absence     of    muscular 
movement  in,  126 
acute,  absence  of  pain  in,  364 

pain  in,  364 
chronic,  causes  of  pain  in,  366 

location  of  pain  in,  367 
diagnostic  criteria  for,  365 
facies  of,  127 
onset   of,  365 
posture  in,   126 
production  of  pain  in,  366 
tenderness   in,   365 
tuberculous,  pain  in,  365 
Peritonsillar  abscess,  340 

incision  of,  351 
Pernicious    anemia,    symptoms    of, 

181 
Peroneal  neuralgia,  147 
Persistency  of  pains,  109 
Pharyngeal    tuberculosis,    pain    of 

swallowing  in,  355 
Phai-yngitis,  types  of,  423,  424 
Pharyngodynia,  pain  of,  352 
Pharynx,  acute  diseases  of,  351 
carcinoma  of,  at  base  of  tongue, 

355 
chronic  diseases  of,  causing  pain, 

354 
febrile  herpes  of,  352 
herpes  zoster  of,   353,   354 
infectious     diseases    of,     causing 
pain,  352 
cases  cited,  353 
inflammatory  processes  of,  351 
luetic  ulcers  of,  355 
neuralgias  of.  356 


Pharynx,  pains  in  diseases  of,  351, 
423 

sensoiy  nerve  of,  351 

tuberculous  ulcers  of,  354 
Phlebitis,     deep     pressure    causing 
painful  reaction  in,  71 

pain  from,  255 
Phlegmonous  angina,  pain  of,  351 
Phlegmonous  pharyngitis,  423 
Photochemical    changes   causing 

pain,  28 
Photophobia,  explanation  of,  323 
Phthisis  of  the  eye,  328 
Physical  consideration  of  pain,  20 
Physical    deterioration    from    pain, 

133,   134 
Physical  factors  of  pain :  change  of 
position,  117 

defecation,  117 

digestion,  116 

drugs,  119 

electricity,  118 

extrinsic,  116^  118 

intrinsic,   116 

menstruation,  116 

modifying  production  of,  116 

motion,  116 

pressure,  118 

respiration,  116 

temperature,  extremes  of,  118 

urination,  116 

weather,  119 
Pinching,  measuring  pain  by,  129 
Pinna,  herpes  of,  333 
Plantar  neuralgia,  169 
Pleasure,     differentiation     between 
pain  and,  16,  17,  18 

pain  related  to,  132 

relation  of,  to  mental  state,  15 

sensations  causing,  13 

transition  to  pain  from,  15,  16 
Pleura,   inflammation  of,  793 

innervation  of,  769 

painful  area  of,  not  necessarily 
indicative  of  pleural  involve- 
ment, 770 


INDEX 


905 


Pleura,  parietal  inflammation  of,  791 
reflected  pain  in,  771 
sensitiveness  to  pain  of,  113 
visceral,  inflammation  of,  792 
Pleural   pain,   764 
Pleurisy,  character  of  pain  in,  770 
diagnostic    value    of    pain    as    a 

symptom  of,  770 
distinguished    from    intercostal 

neuralgia,  165 
posture  in,  127 
respiration  in,  127 
serous,  absence  of  pain  in,  793 
transferred  pain  in,  107 
Plumbism,  484 

Pneumococci  causing  neuralgia,  143 
Pneumonia,  abdominal  pain  of,  392 
association  of,  with  pleurisy,  797 
differential  diagnosis  of,  196 
epigastric  pains  of,  398 
mistaken  for  appendicitis,  797 
pain  of,  797 
referred  pain  in,  799 
slight  pain  in,  113 
transferred  pain  in,  107 
Pneumothorax,  802 
Podalgia,  688 

Points,  distant,  in  neuralgia,  145 
douloureux  apophysaires,  145 
in  neuralgia,  local,  144,  145 
of  pressure,  144,  145 
of  tenderness,  161 
Valleix's,  144,  145 
in  trigeminal  neuralgia,  150 
Signorelli's  spleen,  596 
Poliomyelitis  of  children,  212 
Polycystic   disease   of   the   kidney, 

645 
Polycythemia,  602 
Polymyositis,    acute,    differentiated 
from  eosinophilia,  221 
sj'mptoms  of,  220 
Polyneuritis,    differentiated    from 

poliomyelitis,  213 
Polypoid  growths  inside  of  uterus, 
734 


Polyuria,  with  abdominal  pains,  414 
Pons,  tumors  of,  185 
Portal  vein,  twist  of,  from  liver  dis- 
placement, 559 
Position  assumed  in  lesions  of  the 

middle-ear,  334 
Posterior  comua,   nerve   fibers   en- 
tering, 41,  42 
Posterior  cranial  fossa,  tumors  of, 

186 
Post-hoc  neuralgia,  142 
Postures,  indicating  pain,  in  colic, 
126 
in  disease  of  joint,  127 
in  distention  of  vesical  bladder, 

127 
in  intercostal  neuralgia,  127 
in  peritonitis,  126 
in  pleurisy,  127 
Pregnancy,  back  pains  caused  by, 
303 
hydronephrosis  in,  654 
liver  pain  during,  or  after,  548 
normal,  736 

osteomalacia,  associated  with,  232 
pain  in,  causes  of,  736,  737 
pyelitis  in,   651 
Preprotective    functions    associated 

with  pain,  135 
Prepuce,  inflammation  of,  703 
Pressure,  anesthesia  by,  on  a  nerve 
trunk,  66 
within  nerve  sheath,  66 
aneurysm  indicated  by,  127 
blood,  pain  by  sudden  alterations 

of,  26 
by  new  gi-owths,  25 
causing  affections  of  nerve  recep- 
tors,  140 
of  nerve  trunks,  140 
causing  neuralgia,  142 
constant  pain  caused  by,  109 
deep,   causing   painful  reactions, 

71 
effect  of,  in  neuralgia,  144,  145 
in  neurasthenia,  216 


906 


INDEX 


Pressure,  effect  of,  on  pain  centers, 
64 

from  inflammatory  exudate,  25 

in  colic,  126 

in  distention   of  vesical  bladder, 
127 

measuring  pain  by,  129 

physical  factor  of  pain,  118 

projected  head  pains  due  to,  269 

reaction  to,  in  influenza,  71 
in  phlebitis,  71 

sense  of,  in  head,  264 

slight,  causing  painful  reactions, 
71 

superficial,  painful  reaction  to,  72 

tenderness  produced  by,  70 

three  painful  reactions  to,  71,  72 

tumor  indicated  by,  127 

venous,  headache  due  to  increase 
of,  274 
Pressure  points,  in  hysteria,  79 

in  neuralgia,  144,  145 
Pressure  sense,  46 
Pricking,  73.     See  Paresthesia. 
Primary  paths  in  spinal  cord,  42 
Proctitis,  dysenteric,  507 
Production  of  pain,  causative  fac- 
tors in,  25 

change  of  position  in,  117 

diversion  of  attention  in,  116 

drugs  in,  119 

electricity  in,  118 

emotions  in,  115 

factors  modifying,  115 

in  consciousness,  115 

in  defecation,  117 

in  digestion,  116 

in  menstruation,  116 

in  motion,  116 

in  respiration,  116 

in  urination,  116 

physical  factors  modifying,  116 

pressure  in,  118 

psychical  factors  modifying,  115 

serous    membranes    not    the   seat 
of,  363 


Production  of  pain,  suggestion  in, 
116 
temperature  in,  extremes  of,  118 
weather   in,   119 
Projected  pains,  in  head,  268 

in  neuralgia,  144 
Projection  pain,  103 
relief  of,  in  stump  of  amputated 
limb,  103 
Propagation  of  pain,  89 
Pro i^hy seal  disease   (Marbui'g,  Jel- 

liffe),  224 
Proprioceptive  system  of  Sherring- 
ton, 12 
Prostate,  congestion  and  inflamma- 
tion of,  700 
congestion  of,  without  inflamma- 
tion, 700 
hypertrophy  of,  701 
lesions  of,  701  i 

pain   in,   700 
referred  pain  from,  701 
tuberculosis  of,  702 
tumors  of,  702 
Prostatic     involvement,     associated 

symptoms  of,  702 
Protective      reflexes,     reason     for, 

123 
Protopathic  fibers,  37,  38 
Protopathic  system  of  Head,  11, 12, 

37,  39,  46,  47 
Pseudo-anginal  pain,  784 
Pseudoleukemia,  602 

bone  pains  of,  231,  232,  233 
Psoas  abscess,  causing  pain  in  groin 

and  thigh,  97,  98 
Psychical    factors    of    pain:    con- 
sciousness, 115 
diversion  of  attention,  116 
emotions,   115 

modifying  pain  production,  115 
suggestion,  116 
Psychosis,  pain  perception  in,  62 
Pulse  rate,  indicating  pain,  134 
Purpura  haemorrhagica,  pain  from, 
249 


INDEX 


907 


Pyelitis,  causation  of  pain  in,  647 

character  of  pain  in,  647 

in  pregnancy,  651 

localization  of  pain  in,  647 

pyonephrosis  with,  651 

symptoms  associated  with,  651 
Pyelonephrosis,  649 
Pyemia,    differential    diagnosis    of, 

196 
Pyloric  spasm,  436 

character  of  pain  in,  438 

contraction   in,  437,   438 

tension  j^ains  of,  437 
Pyloric    ulcer,    distinguished    from 
duodenal  ulcer,  450 

severity  of  pain  in,  445 
Pyogenic  mastitis,  258 
Pyonephrosis,  652 

symptoms  associated  with,  653 
Pyosalpinx,  pain  production  in,  745 

B 

Ranulus,  423 
Raynaud's  disease,  248 
Reaction,  of  animals  to  pain,  3 

to  stimuli  without  pain,  4 
Recalled    sensations    in    subjective 

pains  of  hysteria,  75 
Receptive  apparatus  of  pain,  28 
Receptors,  abrogation  of  action  of, 
29 

lowering  of  threshold  values  of, 
30 

of  sensation,  11,  12 

•ense  receptive  organs,  28,  29 

temperature,  35 

terminal  filaments,  28,  29 
Recording  pain,  135 
Rectal  pain,  local,  505 

refen-ed,  506 
Rectal  tenesmus,  688 
Rectum,  carcinoma  of,  507 

gummata  of,  507 

hemorrhoids  of,  508 

inflammation  of,  506 

new  growths  of,  507 


Rectum,  pain  in,  505 

ulceration  of,  508 

varicose  ulcers  of,  508 
Recurrent  paralysis,  relation  to  sen- 
sibility of  the  phaiynx,  357 
Referred  pain,  95 

adrenalin   for,   use  of,   102 

abdominal,  391,  392 

appendiceal,  516,  519 

characteristics  of,  due  to  pres- 
sure on  a  nerve  trunk,  100, 
101 

coal-tar  products  for,  use  of, 
101 

compared  with  gastric,  461 

cord  in'itations  producing,  95 

distal  to  originating  area,  95 

from  the  prostate,  701 

from  viscera  to  head,  290,  291, 
292,  293,  294,  295 

in  alimentary  tract,  425 

in  back,  300 

in  ear,  340 

in  head,  269 

in  heart  disease,  775 

in  labor,  739 

in  laryngeal  diseases,   357 

in  nephritis,  632 

in   penis,  703 

in  temples,  from  carious  teeth, 
264 

incidents  of,  in  groin  from  above 
and  below,  96,  97 

intestinal,   468 

localization  of  viscus  producing, 
388 

locations  of,  95 

morphin,  use  of,  for,  101 

nerv^e  circuit  lesions  causing,  95 

neuralgia  differentiated  from,  102, 
106 

of  cystitis,  687 

of  the  gall-bladder,  567 

of  kidney,    608 

nerves  involved  in,  612 

of  neuralgia,  144,  149,  158 


908 


INDEX 


Referred    pain,    of    renal    calculus, 
659 
of  thoracic  walls,  764 
posterior  root  lesions  causing,  95 
principal  causes  of,  95 
proximal  to  originating  area,  95 
psoas   abscess   causing,   in   thigh 

and  groin,  97,  98 
rectal,  506 

reference   of,   downward,   97,   98, 
100 
upward,  97 

upwai'd  and  downward,  95,  96 
reflected     pains     differentiated 

from,  104 
section  of  nei-ves  causing,  101 
to  extraabdominal  regions,  416 
Reflected  pains,  104 
abdominal,   391,  392 
anatomical  basis  of,  105 
hypogastric,  500 
in  pleura,  770 
intestinal,  467 
localization  of  viscus  causing,  106 

producing,  388 
lowered  vitality  causing,  106 
neuralgia  differentiated  from,  106 
of  bladder,  679 
of  kidney,  614 
of  thoracic  walls,  764 
referred  pains  differentiated  from, 

104 
visceral  irritation  causing,  105 
Reflected  stimuli  in  viscera  (Head's 

law),  384,  385 
Reflex  headaches,  diseases  produc- 
ing, 281 
Reflex  irritations  in  neuralgia,  144 
Reflex  migraine,  286 
Reflex  neuroses  of  nose,  344 
Reflex  organs,  of  muscles,  123 

of  sense,  123 
Reflex  pains,  104 

appendiceal,   517,   521 
in  gastric  area,  433 
in  bead,  269,  277 


Reflex  pains,  of  anal  fissure,  512 
of  the  viscera,  388 

Reflexes,  motor,  protective  tendency 
of,  122,  123 

Regional  pains,  262 
abdominal,  393,  394 
clavicular,  310 
in  abdomen,  307 

in  back,  296,  312,  313,  314,  315 
in  chest,  310 
in  head,  262 
in  limbs,  304 
in  neck,  312 

Remittent  pains,  109 

Removal  of  calcareous  teeth,  pain 
after,  142 
gall-stones,  pain  after,  142 

Renal  calculus,  655 

blocking  of  ureter  in,  657 
blood    pressure,    increase   of,   in, 

667 
character  of  pain  in,  658 
chills  in,   667 
collapse  in,  667 
differential  diagnosis  of,  668 
digestion,  causing  pain  in,  666 
digestive  symptoms  of,  667 
duration  of  the  attack  of,  659 
etiology  of  pain  of,  655 
factors  influencing  pain  of,  665 
hyperalgesic  zones  in,  661 
intermittent  pain  of,  658 
localization  of  stone  in,  664 
location  of  pain  in,  659 
manipulation   of  kidney  inciting 

attack  of,  666 
micturition,  frequency  of,  666 
motion  inciting  to  attack  of,  666 
pain  of,  associated  with  healthy 
instead   of   diseased   kidney, 
662,  663 
paroxysmal  pain  of,  658 
position  of  patient  in,  665 
refeiTed  pain  of,  659 
renorenal  reflex  in,  662 
secondary  pain  in,  657 


INDEX 


909 


Renal  calculus,    sensations   of   cold 
in,  667 
spasms  in,  667 

symptoms    associated    with    pas- 
sage of,  666 
previous  to  attack  of,  667 
temperature,     elevation     of,     in, 

667 
tenderness  in,  664 
urine  changes  in,   667 
Renal  colic,  hyperalgesia  condition 

of  testicle  in,  106 
Renal  infarction,  associated  symp- 
toms of,  628 
causes  of  pain  in,  626 
differential  diagnosis  of,  628 
type  of  pain  in,  628 
Renal  pain.     See  Kidney  pain. 
Renal     tuberculosis,     character     of 
pain  in,  642 
diagnosis  of,  644 
types  of  pain  in,  643 
Renorenal  reflex  in  renal  calculus, 

662 
Reproduction  of  pain,  manual,  132 
Respiration,  indicative  of  pain,  127 

physical  factor  of  pain,  116 
Respiratory  organs,  pain  in,  790 
Respiratory  system,  how  affected  by 

pain,  134 
Retina,  pain  in,  328 
RetropharjTigeal   abscess,   pain  of, 

352 
Rheumatic  headaches,  279,  280 
Rheumatism,  confused  with  myositis 
ossificans,   221 
neuralgia  associated  with,  143 
of  abdominal  wall,  362 
of  back  muscles,  296 
of  eye  muscles,  328 
of  hip  joint,  305 
of  shoulder  joint,  circumflex  neu- 
ralgia mistaken  for,  164 
Rhinological     examination,     impoi-- 
tance    of,    as    a    diagnostic 
measure,  350 


Rhinostenoma,      symptoms     of 

(Piorry),  342 
Rigidity  of  underlying  muscles,  ten- 
derness associated  with,  72 
Robson's  point,  565 
Rules,  Fitz's,  in  pancreatitis,  488 
Rupture,  of  bladder,  685 

of  kidney,  641 

of  spleen,  602 

of  urethra,  696 


Sacral  neuralgia,  169 

differential  diagnosis  of,  171 
general  discussion  of,  170 
herpes  accompanying,  171 
symptoms  of,  169,  170 
Sacral  plexus,  distribution  of  nerves 

from,  53 
Sacroiliac    dislocation,    back    pains 

of,   299 
Sacrovertebral   joints,    diseases    of, 

299 
Salivary  glands,  pain  in,  422 
Salpingitis,    chronic,    pain    produc- 
tion in,  745 
remission  of,  109 
Saponin,  terminal  anesthesia  by,  67 
Sarcoma,   233 

distinguished  from  sciatica,  168 
of  gall-bladder,  571 
of  kidney,  646 
Sciatic  neuralgia,  147,  166 
Sciatic  pains  from  spinal  cord  tu- 
mors, 211 
Sciatica,  166 

character  of  pain  of,  166 
diagnosis  of,  168 
differential  diagnosis,  168,  169 
distinguished     from     gouty     hip 
joint,  245 
pains  of  intermittent  claudica- 
tion, 252 
location  of  pain  of,  166 
and  tenderness  in,  72 


910 


INDEX 


Sciatica,   method   of   eliciting   pain 
in,  169 
Valleix's  points  in,  167,  168 
Scleritis,  pain  of,  327,  328 
Sclerosis,  multiple,  213 

See  Multiple  sclerosis. 
Sclerotic  coat  of  eye,  327 
Secondary    paths    in    spinal    cord, 

42 
Seminal  vesicles,  pain  in,  699 
Senility,    deranged    metabolism    in, 
141 
neuralgia  in,  141 
predisposing  to  neuralgia,  143 
Sensation,  absence  of,  61 
acute,  61 

allied  to  pain,  132 
autosuggestive,  75 
causing  pain,  13 
cell   areas  of,  10 
complexity  of  constituents  of,  11 
conveying  channels  for,  35 
definition  of,  4 
duration  of,  7 

general  consideration  of,  1,  4 
heterosuggestive,  75 
in  lower  animals,  1,  3,  4 
in  muscles  and  skin,  48 
intensity  of,  7 
interpretation  of,  12 
minima    of,    table    representing, 

130 
neutral,  14 
objective,  4 
pain  and  tactile,  8 
pain,  considered  as  an  attribute 
of,  25 
distribution  of,  46 
in  relation  to  other  sensations, 

31 
inhibition  of,  62 
perception  of,  61 
superficial,  46 
perversion  of,  61,  62 
properties  of,  6,  7 
quality  of,  6,  7 


Sensation    recalled,    in    subjective 
pains  of  hysteria,  75 
subjective,  4 
Sense-conveying  organs,  5 
Sense  organs,  centers  for,  7 

classes  of,  11,  12 
Sense-perceptive  centers,  30 
hypersensitiveness  of,  30 
Sense-perceptive   organs,   5,   11 
Sense-receptive  organs,  5 
Senses,  external,  5 

internal,  5 
Sensibility,  abnormal.     See  Hyper- 
algesia. 
Sensibility,  loss  of,  in  lesions  of  the 
thalamus,  200 
mental  activity  of,  13 
Sensitiveness  of  patient,  factor  of 

intensity  of  pain,  115 
Sensiti\eness  to  pain,  development 
of,  112 
individual,  112,  113,  115 
in  infancy,  111 
Sensorimotor  area,  10 
Sensory  area,  10 
convolutions  of,  10 
effect  of  destruction  of,  10 
location  of,  10 
Sensory    examination,    method    of 

making  a,  131,  132 
Sensoi-y  fibers,  10 

arising  in  gray  matter  cells,  42 
ascending  path  of,  45 
association  with  vasomotor  fibers, 

380,  381 
conducting,  course  of,  174 
coui-se  of,  40,  41,  42,  43,  44,  45 
entering  posterior  eornua,  41,  42 
l^eripheral  distribution  areas  of, 
50,  51 
Sensory  mental  activities,  states  of, 

13 
Sensory  nerve  receptors  in  muscleSj 

218 
Sensory  nerves,  areas  of  distribu- 
tion, 47,  48 


INDEX 


9U 


Sensoiy     nerves,     of     the     larynx, 
356 
of  muscles^  50 
of  nose,  341 
Sensory  neurology,  importance  of, 

201 
Sensory  organs,  5,  11 
Sensoiy    perception,    active   agents 
of,  10,  11 
centers  for,  7 
Septic  involvement  of  osseous  sys- 
tem, 231 
Serositis,  universal  chronic,  561 
Severance  of  posterior  roots,  anes- 
thesia produced  by,  66 
Sexual    act    inducing   loss   of   con- 
sciousness, 133 
Sexual    connection,    importance    of 
cure  of  abnormality  in,  758 
pain  in   the  male   during,   759 
pain,    vaginal,    at    beginning   of, 
758 
duiing,  759 
on,  756 
Sexual   indulgence,    excessive,    pre- 
disposing to  neuralgia,  143 
Shock,  indications  of,  124,  125 
susceptibility  to,  125 
with  intestinal  pain,  475 
"without  consciousness,  125 
Shoulder,  pains  above,  769 
pains  in,  304 
reflected  pains  in,  304 
Shoulder  joint,  gonococcus  infection 
of,  304 
rheumatism  of,  304 
Shoulder  pain  in  abdominal  lesions, 

392 
Sigmoid,  obstruction  of,  505 

volvulus  at,  496 
Sigmoid  colon,   lesions  of,   causing 

pain,  494 
Signorelli's  spleen  point,  596 
Simulation  of  pain,  blood  pressure 
elevation    important    in    dis- 
tinguishing, 120 


Sinus  disease,  area  of,  262 

tenderness  in,  significance  of  lack 
of,  262 
Sinus  thrombosis,  differential  diag- 
nosis  of,  195 
Sinuses,  local  pains  in  cavities  of, 
344 
obstructed,   345 
Skin,  as  seat  of  head  pains,  265 

effect  on,  of  neuralgia,  146 
Sleep,   reflex    protective   action   in, 

122 
Sleeping  pains,  305 
Smallpox,  back  pain  with,  297 
Smell,   protective  reflex  action   of, 

123 
Soft  tissues,  neuralgia  from,  142 
Solar  plexus  as  seat  of  epigastric 

pain,  469 
Somatic   areas,    visceral    fibers   re- 
lated to,  54 
Somatic  pain,  visceral,  391 
Somatic  sense  organs,  12 
Sore  throat,  gouty,  423 

streptococcic,  423 
Spasm  in  intestines,  479 
Special  pain  nerves,  25 
Sphenopalatine  ganglion,  headaches 

from  diseases   of,  345 
Sphincter,  pain  in  disease  of,  from 

defecation,  117 
"Spill"  hypothesis  of  perversion  of 

sensation,   62 
Spinal  cord,  back  pains  of,  207 
back  pains  of,  due  to  visceral  dis- 
eases, 207,  208 
caries  of  vertebral  canal,  210,  211 
conditions  of,  causing  pain,  208 
diagnostic  value  of  pains  in,  207, 

208,  216 
diseases  of,  207 

in  which  pain  is  absent,  207 
entrance  of  nerve  fibers  into,  41 
general  summary  of  pains  of,  216 
hematomyelia,  210 
hysteria,  216 


912 


INDEX 


Spinal  cord,  injury  to  pain  conduc- 
tion paths  in,  38,  39 

irregular  distribution  of  pain  in, 
39,  40 

meningeal  apoplexy,  209 

meningitis  of,  212 

multiple  sclerosis,  213 

myelitis,  212 

neurasthenia,  215 

pachymeningitis    spinalis    hyper- 
trophica,  212 

pains   produced   by   diseases   of, 
207,  216 

poliomyelitis  of  children,  212 

primary  paths  in,  42 

radiating  pains  of,  207 

secondary  paths  in,  42 

syphilis  of,  213 

syringomyelia,  214 

tabes  dorsalis,  214 

traumatic  neuroses,  216 

tmnors  of,  211 

unilateral  lesions  of,  39,  40 

vertebra,    luxation    and   fracture 
of,  209 
Spleen,    abscess   of,    601 

anatomy  of,  593 

back  pains  referred  from,  303 

blood   diseases  causing  pain   of, 
602 

character  of  pain  in,  594 

congestion  of,  599 
causes  of,  600 

cysts  of,  602 

differential  diagnosis  of,  603 

diseases  of,  causing  pain,  598 

displaced,   598,   599 

enlargement   of,   from   infectious 
diseases,  600  . 

epigastric  pains  from  lesions  of, 
397 

general  considerations  of,  593 

hydatids  of,  602 

infarct  of,   601 

inflammation  of,  causes  of,  600 

movable,  598 


Spleen,  nerve  supply  of,  593 
pain  in,  594 

factors  influencing,  596 
rupture  of,  602 
Signorelli's  point,  596 
stimuli  of,  594 
symptoms  associated  with  pain  or 

tenderness  of,  598 
tumors  of,  602 
Spleen   pains,   circulatory   changes, 
effect  on,  597 
diaphragmatic  movements,  effect 
on,  597 
Splenitis,  degrees  of  pain  in,  594 
position  of  patient  in,  596 
tenderness  in,  595 

localized  points  of,  596 
Spondylitis,     distinguished     from 

osteomalacia,  232 
Spurs,  bone  pain  of,  233 
Stagnation  mastitis,  258 
State,  of  indifference,  13 

of  sensory  mental  activities,  13 
Static  foot  errors  causing  backache, 

304 
Stenosis,  nasal,  342 

pyloric,  benign,  distinguished 
from  carcinomatous,  457 
Stimulated  surface,  extent  of,  26 
Stimuli,    adequate,    of   the   viscera, 
387 
as   factor   of   intensity   of   pain, 

114 
as  means  of  sensation,  2,  3,  4,  5 
continuous,   114 
due  to  mechanical  changes,  25 
excessive  response  to,  in  diseases 
of   the   thalamus,    200,   201, 
202 
intermittent,  114,  115 
nature  of,  5 
necessaiy  to  pain  reaction,  12 

sensoi-y  reaction,  12 
of  reflected  abdominal  pain,  392 
pain,  by  frequent  repetition  of, 
26 


INDEX 


dl3 


Stimuli,  pain  from  excess  of,  24 

without  presence  of,  141 
Stomach,  acute  dilatation  of,  439 
areas  of  maximum  tenderness  in, 
428 
of  referred  pain,  caused  by  dis- 
orders of,  427 
back  pains  due  to  affections  of, 

301 
causes  of  pain  in,  427 
dilatation  of,  from  pyloric  spasm, 

438 
displacement  of,  431 
epigastric   pain  from  lesions  of, 

397 
hourglass,  cause  of  pain  in,  437 
lesions  of,  causing  pain,  431 
nerve  supply  to,  428 
neuralgia  of,  461,  462 
new  growths  of,  455 
nonresponse  of,  to  chemical  stim- 
uli,   426 
to  tactile  stimuli,  426 
pain  in,  from  change  of  position, 

117 
pain  sensation  of,  426 
See  Gastric, 
sensations  of,  426 
Strangulated  hernia,  mistaken  diag- 
noses of,  374 
pain   in,   374 
Streptococci  causing  neuralgia,  143 
Streptococcic  sore  throat,  423 
Stroking,  measuring  pain  by,  129 
Subjective  pain,  13,  24,  74 
abdominal,   360 
by  hypnosis,  75,  80 
conditions  giving  rise   to,   74 
from  emotional  states,  74,  76 
from  hysteria,  74,  76 
habit  pains,  80 
monomania  pains,  80 
occupation  neuroses,  80,  81 
Suggestion,     psychical     factor     of 

pain  in,  116 
Sunken  globes,  329 


Suppuration  of  middle-ear,  337,  338 
Supraclavicular    pains,    causes    of, 

310,  312 
Supra-orbital    neuralgia,    epidemic, 

143 
Susceptibility,  of  tissues,  to  pain, 
113 
to  pain,  123,  124 
individual,  115 
Sympathetic  fibers,  abdominal  pain 
due  to,  399 
of  abdominal  viscera,  378,  380 
Sympathetic  ophthalmia,  328,  329 
Sympathetic  pains,  102,  103 
abdominal,  393 
of  neuralgia,  144 
Sympathetic  system,  carrying  stim- 
uli, causing  headache,  176 
Symptom,  importance  of  pain  as,  1 
Syncope,  causes  of,  132,  133 

indicating  intensity  of  pain,  124 
indicating  shock,  124,  125 
Synovitis,  acute,  symptoms  of,  234, 

236,  238,  240 
Syphilis,   nocturnal  pain  of,  110 
of  the  brain,  188 

headache  and  other  symptoms 

of,  190 
See   Brain   syphilis. 
of  liver,  556 

of  meninges  and  cord,  213 
of  tongue,  421 

relief     of,     from     mercury     and 
iodids,  119 
Syphilitic  neuralgia,  147 
Syphilitic  process  of  luetic  ulcers, 

355 
Syphilitic   ulceration   of  intestines, 

489 
Syringomyelia,      producing      anal- 
gesia, 62,  66 
symptoms    of,    214 
System,  epicritie,  12 
nervous,  2,  3,  4 

autonomic,  sympathetic,  12 
proprioceptive,  12 


914 


INDEX 


System,  protopathic,  11,  12 
vestibular,  12 


Tabes,  analgesia  produced  by,  66 
differentiated      fro  m      multiple 

sclerosis,   213 
distinguished  from  neuralgia,  149 
sciatica,  168 
Tabes  doi-salis,  95 
associated  symptoms  of,  215 
delayed  pain  sensation  in,  111 
laryngeal  crises  of,  359 
location   of  pain  and  tenderness 

in,  72 
pains  of,  214 
tabetic  crises  of,  214,  215 
Tabetics,  dissociation  between  pain 

and  touch  in,  34 
Taste,   protective  reflex  action   of, 

123 
Teeth,  destruction  of,  420 
pain   in,   419 

destruction  of,  420 
from  neuralgia,  148 
reference  areas  of,  420 
sensitive  part  of,  419 
Temperature,  sensibility  to  changes 
of,  35,  46 
effect  on  pain  pf  changes  in,  119 
elevation  of,  from  pain,  135 
extremes   of,    physical    factor   of 
pain,  118 
Temperature  receptors,  35 
Temperature  senses,  pain  related  to, 

32,  33,  34,  46 
Temporal  lobe  abscess,  339 
Tenderness,  70,  71,  72 

abdominal,  403.     See  Abdominal 
tenderness, 
in  tubal  disease,  720 
area  of,  72 

associated  with  enterospasm,  483 
chronic,  405 
deep,  405 


Tenderness,    hyperalgesia    differen- 
tiated from,  70,  71 
in  appendicitis,  529 
in  kidney  disease,  615 
in  occupation  neuroses,  81 
in  pelvic  pain,  719 
of  the  gall-bladder,  563 
point  of,  in  pelvic  adhesions,  405 
points  of  (Cumston),  405 
(Hubbard),  406 
(McBurney's),  405,  406 
(Mori'is'),   405,   406 
reflected,  405 

rigidity  of  underlying  muscles  as- 
sociated with,  72 
superficial,  405 
temporary,   405 
types  of,  405 

with    intestinal    pain,    diagnostic 
value  of,  474 
Tendon  spindles,  46 
Tension,  as  cause  of  hollow  visceral 
pain  (Hertz),  223 
as  cause  of  visceral  pain,  388 
Tension  pains  of  viscera,  388 
Terminal  anesthesia  by  toxic  agents, 

67 
Terms,  careless  use  of,  409 
Testicles,    deep    pressure    pain    ip, 
698 
enlargement  of,  699 
inflammation  of,   698 
nerve  suj^ply  to,  698 
pain  in,  698 

reflected  kidney  pain  in,  615 
trauma   of,   699 
Tests,  for  diseased  sinus  (Glas'  tun- 
ing fork),  349 
for    eliciting    pain    in    sacroiliac 
region  (Goldthwaite),  300 
Thalamic  center,  202 
Thalamic  functions,  198,  201 
Thalamic  pains,  198 

severity  of,  83 
Thalamic  syndrome,  199 

loss  of  sensibility  in,  199,  200 


INDEX 


915 


Thalamic  syndrome,  overresponse  to 
stimuli  in,  200,  201,  202 
symptoms  of,  199 
Thalamus,  differential  diagnosis  be- 
tween  lesions   of   the  cortex 
and,  203,  204,  205,  206 
essential  organ  of,  201,  202 
functions  of,   201 
interrelations  between  the  cortex 

and,  202 
lesions  of,  199 
loss  of  sensibility  in  lesions  of, 

199,  200 
overresponse  to  stimuli  in  lesions 

of,  200,  201,  202 
pains  of,  198 
paths  of,  201 
Theories  of  pleasure  and  pain,  18, 

19,  20 
Therapeutic    measures    applied    to 

empyema,  348 
Theniial  sensibility,  47 
Thermic  irritations,  parenchymatous 

pains  from,  88 
Thigh  pains,  referred  from  kidney 

lesions,  610 
Third  nerve  palsy,  321 
Thoracic  organs,  diseases  of,  caus- 
ing pain,  795 
Thoracic    pains,    transferred    from 
distention  of  the  stomach,  766 
Thoracic  walls,   referred  pains   of, 
764 
reflected  pains  of,  764 
structures  composing,  760 
transferi'ed  pain  in,  765 
Thorax,  bone  pain  in,  764 
facial  pain  of,  762 
fractures  of,  764 
herpes  zoster  of,  763 
hyperalgesia  of  skin  of,  761 
hyperesthesia  of  skin  of,  761 
hysteria,    tenderness   of   skin   in, 

761 
inflammation  of  skin  of,  761 
muscle  pain  of,  762 


Thorax,  nerve  pain  of,  762 

neuralgia  of,  760,  763 

neuritis  of,  762 

osteomyelitis  of,  764 

pains  within,  769 

pleural  pain  of,  764 

skin  affections  of,  760 
Threshold  values  of  pain,  loweriog 

of,  30 
Throat,  pain  in  diseases  of,  laryn- 
geal, 356 
pharyngeal,  351 
Thrombo-endarteritis  obliterans,  249 
Thrombosis  of  arteries,  248 

differential     diagnosis     of,     196, 
198 

of  mesenteric  arteries,  253,  254 

of  veins,  256 
Thymus  gland,  pain  in,  261 
Thyroid  gland,   pain   in,  261 
Tic  douloureux,  420 

of  herpes  zoster,  354 

douloureux.    See  Trigeminal  neu- 
ralgia. 
Tickling,  73.     See  Paresthesia. 
"Time  of  life"  pains,  410 
Time  of  pain,  110 
Tingling,  73.     See  Paresthesia. 
Tissue  susceptibility  to  pain,  113 
Tissues,  fatty,  pain  in,  224 

glandular,  257 

muscular,  pain  in,  218 
Tobacco,  predisposing  to  neuralgia, 

143 
Tongue,  carcinoma  of  base  of,  355 

lesions  of,  an  indication  of  a  noc- 
turnal epileptic  attack,  422 
causing  pain,  421,  422 

pain  in,  421 

reference  areas  in  diseases  of,  422 

ulcer  of,  419 
Tongue  pains.     See  Glossodynia. 
Tonsils,   pain  in,  423 
Toothache,  causes  of,  419 

trigeminal     neuralgia     mistaken 
for,   420 


S16 


INDEX 


Torsion,    parenchymatous    pains 

from,  88 
Torticollis,  221,  222,  296 
Touch,  dissociation   of,  from  pain, 
32,  33,  34 
perception  of,  in  anesthesia,  63 
Toach  sense,  in  localizing  pain,  48 
Toxemia,  causing  affections  of  nerve 
receptors,  140 
causing  affections  of  nerve  trunks, 

140 
pain,  cause  of,  26,  27 
pain  perception  in,  62 
with  abdominal  pains,  414 
Toxemic    headaches,     due    to    en- 
dogenous poisons,  271 
due  to  exogenous  poisons,  271 
due  to  starvation  products,  272 
Toxic  agents,  anesthesia  by,  67 
Toxic  analgesia,  62 
Toxic  materials,  pain  from,  142 
Toxic  products,  pain  from  accumu- 
lation of,  27 
Traction,  cause  of  pain  in  viscera, 
390 
parenchymatous  pains  from,  88 
Transferred  pains,  95,  106 
abdominal,  392 
appendiceal,  516,  520 
cause  for  persistency  of,  108 
in  breast,  258 

in  homologous  segments,  107 
in  thoracic  walls,  765 
in  urethral  disease,  696 
neuralgia    differentiated    from, 

106 
occurring  in  cord,  107 
reference  higher  and  lower,  107 
sympathetic    pain,    differentiated 
from,  102 
Transverse  myelitis,  95 

anesthesia  produced  by,  66 
Trauma,  habit  pains  resulting  from, 

80 
Traumatic  neuroses,  216 

differential  diagnosis  of,  196 


Traumatism,   causing  affections  of 
nerve  trunks,  140 
neuralgia,  143 
of  bones,  229 
Trigeminal  neuralgia,  146,  147,  148, 
149 
area  of,  262 

associated  with  tumors,  183 
characteristics  of,  149 
mistaken  for  toothache,  420 
Valleix's  points  in,  150 
Trigeminus,   pains  in  head  due   to 

action  on  receptors  of,  82 
Trophic    changes,    from    neuralgia, 
146 
in  skin,  causing  pain,  28 
resulting  from  pain,  134,   135 
Tropical  abscess  of  liver,  554 
Tubal  inflammation,  adhesions  from, 
746 
functional  acts,  pain  in,  745 
uterine  colic  from,   746 
Tuberculin,  use  of,  119 
Tuberculosis,    effect    of    tuberculin 
in,  119 
of  hip  joint,  305 
of  kidney,  642 
of  ovary,  752 
of  prostate,  702 
of  tongue,  421 
of  vertebrae,  211' 
of  vulva,  756 

pain  from  enlargement  of  mesen- 
teric glands  in,  261 
pharyngeal,  355 
pulmonai*y,  800 

causes  of  thoracic  pain  in,  802 
character  of  pain  in,  800 
pleurisy  during,  802 
pneumothorax  during,  802 
tenderness  in,  800 
Tuberculous   caries,   back   pain   of, 

299 
Tuberculous  hip  diseases,  symptoms 
of,  241 
treatment,  243 


INDEX 


917 


Tuberculous  meningitis,  differential 
diagnosis  of,  197 

headache  in,  ISO 

symptoms  of,  180 
Tuberculous   peritonitis,  365 
Tuberculous  ulcers,  intestinal,  488 

of  larynx,  358 

phaiyngeal,  354 
Tumor,     brain,    270.       See    Brain 
tumor. 

cerebral,  269 

distinguished  from  sciatica,  168, 
169 

gummatous  masses  similar  to,  211 

nasal,  347 

neuralgia  due  to,  142 

of  base  of  brain,  186 

of  bladder,  689 

of  brain,  182 

of  breast,  259 

of  central  ganglion,  185 

of  cerebellopontine  angle,  183 

of  cerebellum,  185 

of  chiasma,  183 

of  corpora  quadrigemina,  185 

of  corpus  callosum,  184 

of  frontal  lobe,  184 

of  hypophysis,  186 

of  kidney,  646 

of  medulla,  186 

of  parietal  lobe,  184 

of  pedunculi  cerebri,  185 

of  peritoneum,  367 

of  pons,  183,  185 

of  posterior  cranial  fossa,  186 

of  prostate,  702 

of  spinal  cord  and  vertebra,  211 

of  spleen,  602 

pressure  indicating,  127 

visceromotor  reflex  mistaken  for, 
445 
Twisted  pedicle,  cysts  from,  399 

diagnosis  of,  399 
Tympanum,  pain  in,  335 
Typhoid  fever,  differential  diagnosis 
of,  196 


Typhoid  fever,  neuralgia  associated 
with,  143 
neuritis  of  toes  in,  169 
nocturnal  ostalgia  with,  228 
perforations  in,  402,  403 
spleen,  enlargement  of,  from,  600 
Typhoidal   ulceration  of  intestines, 
488 

U 

Ulceration,  of  intestines,  catarrhal, 
489 
syphilitic,  489 
typhoidal,  488 
rectal,  508 
Ulcerative  colitis,  501 
Ulcer   of   stomach,   chronic,   distin- 
guished  from   gastric   ulcer, 
451 
distinguished    from    cancer    and 
nervous  gastralgia,  452,  453, 
454,  455 
Ulcers,  duodenal,  489 
following  burns,  489 
of  intestines,  487 
of  tongue,  419,  421 
perforating,  449 
tuberculous,  of  intestines,  488 
of  pharynx,  358 
Umbilical  hernia,  local  and  referred 

pain  of,  374 
Umbilical  pain  in  intestinal  lesions, 

469 
Universality  of  pain,  20 
Uremia,  colic  with,  484 

differential  diagnosis  of,  197 
nocturnal  pain  of,  110 
Ureter,  inflammation  of,  670 

location  of  pain  in  inflammation 

of,  671 
muscular  spasm  in,  670 
nerve  supply  to,  670 
obstruction  of,  670 

complete,  671 
pain  associated  with,  670 
tumor  of,  671 


918 


INDEX 


Ureteral  colic,  cause  of  pain  in  tes- 
ticle in,  105 
Ureteral  disease,  route  of  pain  ref- 
erence in,   671 
Ureteral   stone,   reference  pains  in 

groin  from,  671 
Ureteritis,  670 
Urethra,  pain  in,  695 
Urethral  calculus,  696 
Urethral  caruncles,  695 
Urethral   disease,   transfeiTcd   pain 

in,  696 
Urethral  rupture,  696 
Urethritis,  695,  703 

epididymis  involved  in,  699 
Urine,  irritating  constituents  in,  696 
Urination,    burning   sensation    dur- 
ing,   697 
pain  after,  causes  of,  697 
pain  during,  due  to  inflammatory 

changes,  697 
pain  on,  696 

painful  in  bladder  diseases,  682 
physical  factor  of  pain   in,   116 
Uterine  colic  from  tubal  inflamma- 
tion, 746 
Uterine    muscle,    hyperesthesia    of, 

731 
Uterine  pain,  character  of,  716,  724 
constant,  716 
disorders  causing,  726 
due  to  cervical  stenosis,  729 
due  to  hindrance  to  the  separa- 
tion  of    the   decidual   mem- 
brane, 730 
due  to  spasmodic  contraction  of 

cervix,  730 
in  childbirth,  738 
in   pregnancy,   736 
intensity   of,   726 
intermittent,  716 
irregular  intensity  of,  724 
tenderness  with,  area  of,  721 
Uterus,   back  pains  referred  from, 
303,   304 
benign  growths  of,  743 


Uterus,  cancer  of,  744 

correlation    of,    through   nervous 

system  with  breast,  715 
displacement  of,  726 
character  of,  727 
enlarged,    pain    in    ovaiy    from, 

752 
fibroids  of,  744 
functional  disorders  of,  728 
inflammation  of,  740 
maldevelopment  of,  731 
malignant  growths  of,  743 
menstruation,   painful,  to,  728 
nerve  supply  to,  707,  713,  724 
neuralgia  of,  726 
new  growths  of,  743 
Ijolypoid  growths  inside  of,  734 


Vagina,  affections  of,  causing  pain, 
755 
cancer  of,  756 
hemorrhage   into    the   soft   parts 

surrounding,  756 
nerve  supply  to,  755 
nodule  on,   756 
pain   in,   755 
Vagus     and    greater     splanchnics, 

pain  conductivity  of,  383 
Valleix's   points,   71 
in  neuralgia,  144,  145 
in  sciatica,  167,  168 
in  trigeminal  neuralgia,  150 
Varicose  veins,  256 
Varieties  of  i^ain,  origin  and  ti'ans- 
mission,  diagrams  of,  89,  90, 
91 
Vas  deferens,  pain  in,  699 
Vasomotor    changes    in    neuralgia, 

145 
Vasomotor    fibers    associated    with 

sensory  fibers,  380,  381 
Vasomotor  paresis,  133 
Vasomotor    signs    of   intensity    of 
pain,  120,  124 


INDEX 


919 


Vasoneurosis,  72 

Veins,    diseases    of,    causing    pain, 
255 
inflammation  of,  255 
thrombosis  of,  256 
Vena  cava,  pull  on,  from  liver  dis- 
placement, 559 
VeiTuiform    appendix,    diseases    of, 

.      529 
Vertebra,    caries   of  the   canal   of, 
210,  211 
luxation   and  fracture   of,   pains 
produced  by,  208 
symptoms  of,  209 
tumors  of,  211 
Vertebral  diseases,  dislocations,  299 
leukemia,  299 

of  saei'o vertebral  joints,  299 
tuberculous  caries,  299 
Vertebral   pains,   indications   from, 

312 
Vesical   calculus,   absence   of   pain 
in,  695 
causes  of  pain  in,  692 
character  of  pain  in,  693 
digestion  in,  695 
location   of  pain  in,  694 
motion,  causing  pain  in,  694 
position  of  patient  in,  694 
production  of  pain  in,  factors  in- 
fluencing, 694 
Vesical  jilexus,  contributing  to  blad- 
der, 674 
Vesicles,  in  cheeks,  419 

on  tongue,  421 
Vesicourethral  fissure,  684 
Vestibular  nerve,  12 
Vestibular  system,  12 
Vibration  as  stimulus  of  sensation, 

5,  6 
Viscera,  abdominal,  absence  of  pain 
in  lesions  of,  390 
adequate  stimuli   (Hertz),  387 
areas  of  hyperesthesia  in  (Mac- 
kenzie's),  385 
cocain  anesthesia  in,  382 


Viscera,  abdominal,  examples  of  ir- 

sensitiveness  of,  381 
gangrene  of,  417 
hyperalgesia,     persistence     of, 

386 
hypoalgesia  in  (Wilamowski's), 

385 
innervation  of,  378 
insensitiveness  of,  to  pain,  381, 

382 
irritable  foci  produced  in  cord 

by  lesions  of,  386 
lesions     of,     producing     pain, 

390 
location  of  pain  in  diseases  of, 

383,   384 
manner  of  pain  production  and 

conduction,  383 
maximum  points  of  tenderness 

of,  393 
nonpainful  diseases  of,  393 
pain  conductivity  of  vagus  and 

greater  splanchnics,  393 
pain  of,  due  to  contraction  and 
dilatation  of,  390 

due  to  spasmodic  contrac- 
tions and  dilatations  of, 
391 

due  to  traction  on  mesentery, 
390 

from  passive  dilatation  of, 
390 

perception  in,  377 
perforation  of,  416 
phenomena  present  with  inflam- 
mation, 378 
reflection  of  stimuli  in  (Head's 

law),  384,  385 
reflex  changes  in,  389 
sensitiveness  of,  to  deep  pres- 
sure stimuli,  387 
sensory  fibere  of,  380 
shock    production    of    painful 

stimuli,  387 
stimuli     in,     pain     producing, 

380 


920 


INDEX 


Viscera,  abdominal,  transference  of 
pain,  manner  of  (Head),  384 
zones     of     hyperalgesia     in 
(Head's),  384,  385 
Viscera,  absence  of  pain  in  inflam- 
mation of,  8G,  87 
back  pains  due  to  lesions  of,  208 
causing   referred    pain   in    head, 
290,  291,  292,  293,  294,  295 
inaccuracy  of  localization  of  ten- 
sion pains  in,  388 
irritation    of,     causing    reflected 

pain  in,  105,  106 
pain   in  involuntary   muscles  of, 

222 
referred  pains  to  back  from,  300 
Visceral  diseases,  surface  zones  re- 
lated to,  54 
Visceral  nerves,  41 
Visceral  neuralgia,  147 
Visceral  pain,  mobility  of  organ  in 
localization  of,  470 
produced  by  traction  of  mesen- 
teiy,  381 


Visceral    pain,    tension    only    true 

cause  of  (Hertz),  388 
Visceromotor  reflex,  mistaken  for  a 

tumor  (Mackenzie),  445 
Visceromuscular  reflex,  413 
Volition,  mental  activity  of,  13 
Voluntary  analgesia,  62,  63 
Voluntary  lameness,  symptoms  of, 

241 
Volvulus,  496 
Vomiting,    protective   reflex   action 

of,  123 
with  intestinal   pain,  474 
Von  Frey  hairs,  measuring  pain  by, 

130,   131 
Vulva,  cancer  of,  756 
cysts  of,  756 
tuberculosis  of,  756 


W 

Weather,   effect   of,   on    pain   pro- 
duction,  119 


(7) 


Date  Due 

PRINTED  IN  U.S.A.              CAT     NO.    24    161                BBS 

A  000  510  153  0 


vmiT6 

eU19p 

1920 

Behan,  Richard  J 

Pain  . . . 

"Behan,  Pichard  J 
Pain  . . . 


B^lPp 
1920 


MEDICAL  SCIENCES  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92684 


